DO NOT RESUSCITATE (DNR) MEDICAL DIRECTIVE
(NEW HAMPSHIRE – NON-HOSPITAL SETTING)
[// GUIDANCE: This template is drafted to conform to current New Hampshire requirements for a Do Not Resuscitate order that is effective outside a hospital environment and is intended to be recognized by EMS personnel statewide. Customize all bracketed items and review against the most recent statutory and regulatory guidance before execution.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
1.1 Title. Do Not Resuscitate (DNR) Medical Directive and Non-Hospital DNR Order.
1.2 Parties.
(a) “Patient”: [FULL LEGAL NAME], DOB: [MM/DD/YYYY], residing at [ADDRESS] (“Patient”).
(b) “Authorized Practitioner”: [NAME, CREDENTIALS (M.D./D.O./APRN/PA-C)], license no. [_] (“Practitioner”).
1.3 Recitals.
A. Patient desires to control health-care decisions in the event of cardiopulmonary arrest outside a hospital.
B. Practitioner attests that Patient is capable of executing this Directive, or that an authorized surrogate is acting pursuant to valid authority.
C. Both parties intend this Directive to be binding on all health-care providers and emergency medical services (“EMS”) personnel acting in good faith within New Hampshire.
1.4 Effective Date. This Directive becomes effective upon the latest signature date appearing in Section 10 (Execution Block) and remains in force until revoked pursuant to Section 9.2.
1.5 Governing Law. This Directive is governed by applicable New Hampshire statutes and regulations pertaining to advance directives and non-hospital DNR orders (“NH Health-Care Law”).
2. DEFINITIONS
For purposes of this Directive, capitalized terms have the meanings set out below.
“Cardiopulmonary Arrest” – The absence of a palpable pulse and spontaneous respirations.
“Cardiopulmonary Resuscitation” or “CPR” – Chest compressions, artificial ventilation, defibrillation, advanced airway management, administration of cardiac resuscitative medications, or any combination thereof.
“EMS Personnel” – Licensed emergency medical responders, emergency medical technicians, advanced EMTs, and paramedics operating under New Hampshire protocols.
“Good Faith Compliance” – Actions or omissions reasonably believed to be in accordance with this Directive and NH Health-Care Law.
“Qualified Health-Care Provider” – A person licensed or certified under NH law to administer medical treatment, including but not limited to physicians, APRNs, PAs, RNs, and EMS Personnel.
“Revocation” – A valid act by Patient or surrogate that terminates this Directive pursuant to Section 9.2.
3. OPERATIVE PROVISIONS
3.1 DNR Instruction. In the event of Cardiopulmonary Arrest, Patient DIRECTS that no Qualified Health-Care Provider initiate or continue CPR. All other medically indicated comfort care (e.g., oxygen, pain medication, suctioning, bleeding control) is authorized.
3.2 Scope of Treatment Withheld. Without limitation, the following interventions are specifically refused:
(a) External chest compressions;
(b) Defibrillation or cardioversion;
(c) Endotracheal or supraglottic airway placement for ventilatory support;
(d) Positive-pressure ventilation (manual or mechanical);
(e) Cardiac resuscitation drugs (e.g., epinephrine, vasopressin, amiodarone).
3.3 Display & Identification.
(a) Patient shall keep the original of this Directive readily available and, when feasible, on person during transport.
(b) Practitioner may issue an approved DNR bracelet/necklace reflecting the existence of this Directive.
(c) EMS Personnel presented with (i) the original Directive, (ii) a legible copy, or (iii) an approved identification device shall honor the Directive pursuant to NH EMS protocols.
3.4 Medical Record Entry. Practitioner shall place a copy of this Directive in Patient’s medical record within [24] hours of execution.
4. REPRESENTATIONS & WARRANTIES
4.1 Patient Representations.
(a) Patient is at least 18 years of age (or an emancipated minor) and of sound mind, or this Directive is executed by a legally authorized surrogate.
(b) Execution is voluntary and not the result of fraud, duress, or undue influence.
4.2 Practitioner Certification. Practitioner confirms:
(i) Patient (or surrogate) understands the nature and consequences of a DNR order;
(ii) No medical evidence suggests Patient lacks decision-making capacity;
(iii) This Directive complies with NH Health-Care Law and prevailing professional standards.
4.3 Survival. The representations and warranties in this Section survive Patient incapacity and remain operative until Revocation.
5. COVENANTS & RESTRICTIONS
5.1 Patient Covenants.
(a) Patient shall inform close family members, caregivers, and residential facilities of this Directive.
(b) Patient shall request destruction of any existing, conflicting DNR forms immediately upon execution of this Directive.
5.2 Practitioner Covenants.
(a) Practitioner shall review the Directive with Patient at least annually or upon any material change in Patient’s condition.
(b) Practitioner shall promptly communicate the existence of this Directive to other treating providers.
6. DEFAULT & REMEDIES
6.1 Event of Default. Any material deviation by a Qualified Health-Care Provider from Section 3 constitutes a “Default.”
6.2 Notice & Opportunity to Cure. Because timeliness is critical, cure periods are impracticable; however, providers shall document the grounds for deviation as soon as possible after the event.
6.3 Remedies. Subject to Section 7, providers acting outside Good Faith Compliance may be subject to professional discipline and civil liability under NH Health-Care Law.
[// GUIDANCE: In practice, enforcement is typically administrative or civil; criminal liability is rare absent gross misconduct.]
7. RISK ALLOCATION
7.1 Provider Indemnification. Patient (and Patient’s estate) agrees to indemnify and hold harmless any Qualified Health-Care Provider who, in Good Faith Compliance, withholds or withdraws CPR consistent with this Directive (“Provider Protection”).
7.2 Limitation of Liability. No Qualified Health-Care Provider or EMS Personnel acting in Good Faith Compliance shall be liable for civil damages or subject to criminal prosecution for honoring this Directive (“Good Faith Standard”).
7.3 Insurance. Patient acknowledges sole responsibility for any insurance implications arising from refusal of resuscitative care.
7.4 Force Majeure. Providers are excused when extraordinary circumstances (e.g., mass-casualty incident) render compliance impossible.
8. DISPUTE RESOLUTION
8.1 Governing Law. All disputes concerning this Directive are governed by NH Health-Care Law without regard to conflict-of-laws principles.
8.2 Forum. Because this is a health-care directive, judicial relief shall be sought, if at all, in the appropriate New Hampshire probate or superior court having jurisdiction over Patient’s residence.
8.3 Injunctive Relief. The court may issue emergency orders to enforce or enjoin actions inconsistent with this Directive.
[// GUIDANCE: Arbitration, jury waiver, and similar commercial clauses are intentionally omitted as inconsistent with the nature of a medical directive.]
9. GENERAL PROVISIONS
9.1 Amendment. Patient may amend this Directive only by executing a new document meeting NH Health-Care Law requirements.
9.2 Revocation.
(a) At any time, Patient (or authorized surrogate) may revoke orally or in writing, or by destroying all copies of this Directive.
(b) Revocation is effective immediately upon communication to any Qualified Health-Care Provider.
9.3 Severability. If any provision is held invalid, the remaining provisions shall remain enforceable to the fullest extent permitted by law.
9.4 Integration. This Directive constitutes the entire agreement concerning resuscitative measures and supersedes all prior inconsistent directives.
9.5 Counterparts & Electronic Signatures. This Directive may be executed in counterparts and by electronic signature with the same force and effect as originals, provided all statutory formalities (including witness signatures) are satisfied.
10. EXECUTION BLOCK
[// GUIDANCE: New Hampshire requires TWO adult witnesses who are not the Practitioner, the Patient’s health-care agent, spouse, parent, child, or heir-at-law. Notarization is optional but recommended for evidentiary clarity.]
10.1 Patient (or Authorized Surrogate)
Signature: ______
Printed Name: _____
Date: _______
Capacity (if not Patient): □ Agent under Durable Power of Attorney for Health Care □ Guardian □ Other: ______
10.2 Authorized Practitioner
I hereby issue a medical order that resuscitative efforts SHALL NOT be initiated for the above-named Patient in the event of Cardiopulmonary Arrest outside a hospital setting.
Signature: ______
Printed Name & Credentials: __
License No.: _____
Date: ___
Telephone: _________
10.3 Witnesses
Witness #1
• Signature: ____
• Printed Name: _____
• Address: ____
• Date: ______
Witness #2
• Signature: ____
• Printed Name: _____
• Address: ____
• Date: ______
Each witness declares under penalty of perjury that:
(a) The Patient (or surrogate) signed or acknowledged this Directive in the witness’s presence;
(b) The witness is at least 18 years of age, not related to Patient by blood, marriage, or adoption, not entitled to any portion of Patient’s estate, and not directly responsible for Patient’s medical care; and
(c) The witness is not serving as Patient’s designated agent or Practitioner.
10.4 Optional Notarization
State of New Hampshire
County of ____
On this ___ day of _, 20, before me, _____, a Notary Public, personally appeared [Patient/Surrogate], known to me or satisfactorily proven to be the person whose name appears above, and acknowledged executing this Directive as a free and voluntary act.
Notary Public Signature: ____
Printed Name: ____
My Commission Expires: _____
10.5 EMS Confirmation (Optional)
The undersigned EMS Provider acknowledges receipt and visual inspection of this valid Directive on //____ and will enter the order into the electronic patient care report (ePCR).
Signature: ___ Printed Name/ID: ______
[// GUIDANCE:
1. Advise Patient to carry a wallet card referencing this Directive and, if desired, to obtain an approved DNR bracelet/necklace.
2. Place a copy in all relevant medical records (primary care, specialist, long-term care facility, hospice).
3. Review annually or upon any substantial change in Patient’s health status or treatment goals.
4. Destroy outdated versions immediately upon amendment or revocation to avoid conflicting instructions.]