Medical Directive - DNR

NEBRASKA OUT–OF–HOSPITAL

DO-NOT-RESUSCITATE (“DNR”) DIRECTIVE

DOCUMENT HEADER

1. Parties & Effective Date
This Out-of-Hospital Do-Not-Resuscitate Directive (the “Directive”) is made effective as of [EFFECTIVE DATE] (the “Effective Date”) by [FULL LEGAL NAME OF PATIENT], date of birth [MM/DD/YYYY], residing at [ADDRESS] (the “Principal”).

2. Recitals
A. Nebraska’s Natural Death Act, Neb. Rev. Stat. §§ 30-3401 et seq., authorizes a competent adult to direct the withholding of life-sustaining procedures.
B. The Principal desires, in accordance with said Act and applicable EMS protocols, that no cardiopulmonary resuscitation (“CPR”) be initiated in the event of cardiac or respiratory arrest occurring outside a hospital.
C. The Principal’s attending physician concurs with and hereby authenticates this Directive to ensure recognition by emergency medical service (“EMS”) personnel and other health-care providers.

TABLE OF CONTENTS

I. Definitions
II. Operative Provisions
III. Representations & Warranties
IV. Covenants
V. Risk Allocation
VI. Revocation & Amendment
VII. Miscellaneous
VIII. Execution Block

I. DEFINITIONS

1. “Attending Physician” means the Nebraska-licensed physician who has primary responsibility for the Principal’s medical care and who signs this Directive.
2. “Cardiopulmonary Resuscitation” or “CPR” includes chest compressions, defibrillation, medication administration, airway management, or any similar resuscitative measure intended to restore cardiac or respiratory function.
3. “Directive” has the meaning set forth in the header.
4. “EMS” means any licensed emergency medical responder, emergency medical technician, paramedic, or other out-of-hospital medical personnel operating under Nebraska EMS regulations.
5. “Good Faith” means honesty in fact and the observance of reasonable medical standards prevailing at the time of treatment.
6. “Health-Care Provider” includes any physician, nurse, hospital, hospice, long-term-care facility, or EMS provider subject to Nebraska law.
7. “Principal” has the meaning set forth in the header.

II. OPERATIVE PROVISIONS

2.1 Direction to Withhold CPR
The Principal unequivocally directs that no CPR be administered if the Principal experiences cardiac or respiratory arrest at any location outside an acute-care hospital.

2.2 Scope
(a) This Directive applies to all out-of-hospital settings, including but not limited to the Principal’s residence, assisted-living facilities, nursing homes, clinics, ambulances, and public places.
(b) The Directive authorizes the withholding or withdrawal of CPR only; it does not prohibit palliative care, pain management, comfort measures, or other medically indicated treatments that do not constitute resuscitation.

2.3 EMS Recognition
(a) EMS personnel presented with:
(i) the original, a copy, or an electronic image of this executed Directive; or
(ii) a DNR identification bracelet/necklace issued pursuant to Title 172 NAC 12 (Out-of-Hospital DNR Regulations),
shall honor its instructions in accordance with Nebraska EMS protocols.
(b) EMS may provide supportive care (e.g., airway suctioning, oxygen, hemorrhage control) consistent with standard comfort-care measures.

2.4 Conditions Precedent
This Directive becomes operative only upon the occurrence of both:
(i) cardiac or respiratory arrest; and
(ii) confirmation of authenticity by EMS or another Health-Care Provider acting in Good Faith.

2.5 Exceptions
(a) If the Principal is pregnant and it is medically probable that the fetus could develop to the point of live birth with continued life-sustaining treatment, Nebraska law may require providers to disregard this Directive.
(b) If the Principal revokes this Directive in any manner set forth in Section VI prior to arrest, the revocation controls.

III. REPRESENTATIONS & WARRANTIES

3.1 Principal’s Representations
(a) Capacity: The Principal is of sound mind and at least eighteen (18) years of age.
(b) Voluntariness: The execution of this Directive is voluntary and free from duress or undue influence.
(c) Informed Decision: The Principal has discussed the consequences of this Directive with the Attending Physician and understands its effect.

3.2 Physician’s Warranty
The Attending Physician (i) has confirmed the Principal’s decisional capacity; (ii) has reviewed this Directive for compliance with Nebraska law; and (iii) is satisfied that the Principal’s instructions are medically appropriate.

3.3 Survival
All representations and warranties survive execution and remain effective for the duration of this Directive.

IV. COVENANTS

4.1 Distribution
The Principal covenants to provide a copy of this Directive to: (a) all primary Health-Care Providers; (b) immediate family members or legal guardians; and (c) any home health or hospice agency involved in the Principal’s care.

4.2 Identification
The Principal authorizes issuance of an approved DNR bracelet/necklace and covenants to wear such identification whenever practicable.

4.3 Updates
The Principal shall notify Health-Care Providers of any revocation, suspension, or amendment pursuant to Section VI.

V. RISK ALLOCATION

5.1 Indemnification (Provider Protection)
The Principal and the Principal’s heirs, executors, administrators, and assigns hereby release, indemnify, and hold harmless any Health-Care Provider or EMS personnel who, in Good Faith, withhold or withdraw CPR in reliance on this Directive.

5.2 Limitation of Liability (Good-Faith Standard)
No Health-Care Provider shall incur civil or criminal liability or be found to have engaged in unprofessional conduct for acting or declining to act in Good Faith pursuant to this Directive.

5.3 Injunctive Relief
The Principal and the Principal’s estate reserve the right to seek injunctive relief to enforce or prevent unauthorized alteration of this Directive.

VI. REVOCATION & AMENDMENT

6.1 Revocation Methods
This Directive may be revoked at any time by the Principal:
(a) destroying or defacing the original document;
(b) orally expressing intent to revoke in the presence of a witness age 18 or older; or
(c) executing a subsequent DNR or other advance directive inconsistent herewith.

6.2 Effect of Revocation
Revocation is effective immediately upon the occurrence of any method in § 6.1, and all Health-Care Providers shall be promptly notified.

6.3 Amendment
Any amendment must: (i) be in writing; (ii) reference this Directive’s Effective Date; and (iii) be executed with the same formalities as this Directive. Partial amendments are not permitted.

VII. MISCELLANEOUS

7.1 Governing Law
This Directive shall be governed by and construed in accordance with the health-care laws of the State of Nebraska, without regard to conflict-of-laws principles.

7.2 Severability
If any provision of this Directive is held invalid, the remaining provisions shall nevertheless remain in full force and effect to the fullest extent permitted by law.

7.3 Entire Agreement
This Directive constitutes the entire out-of-hospital DNR instruction of the Principal and supersedes all prior oral or written statements concerning resuscitation preferences.

7.4 Copies
Photographic or electronic copies of this executed Directive shall be as valid as the original.

7.5 Counterparts & Electronic Signatures
This Directive may be executed in counterparts, and signatures transmitted by electronic means (e.g., PDF, fax) shall be deemed original signatures for all purposes.

VIII. EXECUTION BLOCK

A. Principal’s Signature

I, the undersigned Principal, hereby execute this Directive on the Effective Date stated above.

______________________________      ____________________
[PRINTED NAME OF PRINCIPAL]         Date
Signature: ______________________

B. Attending Physician’s Authentication

I, the undersigned Nebraska-licensed physician, affirm that I am the Attending Physician of the Principal, that the Principal is competent, and that I concur with this Directive.

______________________________      ____________________
[PRINTED NAME, M.D./D.O.]           Date
Nebraska License No.: _____________
Signature: ______________________

C-1. Witnesses (if using witness option)

We declare that (i) we are at least 18 years of age; (ii) we are not related to the Principal by blood, marriage, or adoption; (iii) we are not entitled to any portion of the Principal’s estate; and (iv) we are not directly involved in the Principal’s medical care.

C-2. Notary Acknowledgment (alternative to witnesses)

State of Nebraska )
) ss.
County of _________ )

On this ____ day of __________, 20____, before me, the undersigned Notary Public, personally appeared [NAME OF PRINCIPAL], known to me or satisfactorily proven to be the person whose name is subscribed to the within instrument, and acknowledged that he/she executed the same for the purposes therein contained.

Notary Public: __________________________
My Commission Expires: _________________

D. EMS Verification (Optional)

Date Received by EMS Agency: _____________
Authorized EMS Representative: _________________________