OUT-OF-HOSPITAL DO NOT RESUSCITATE (DNR) DIRECTIVE

(New York – N.Y. Pub. Health Law art. 29-B)

[// GUIDANCE: This template is designed for use outside of a hospital or nursing home setting (e.g., private residence, assisted-living, ambulance transport, etc.). It is NOT a Living Will or MOLST form. It tracks the statutory requirements for an “Out-of-Hospital DNR Order” under New York Public Health Law Article 29-B and the corresponding Department of Health (“DOH”) form DOH-3474. Practitioners should customize bracketed items, print on distinctive paper, and distribute originals/copies per Section III(F).]

I. DOCUMENT HEADER

1. Title Out-of-Hospital Do Not Resuscitate Directive (the “Directive”).
2. Effective Date This Directive is effective as of [EFFECTIVE DATE] (the “Effective Date”) and remains in force until revoked pursuant to Section VI.
3. Jurisdiction & Governing Law This Directive is governed by New York Public Health Law Article 29-B and all other applicable New York State and federal healthcare laws and regulations (collectively, the “Governing Law”).

4. Parties and Identification
   a. Patient: [PATIENT FULL LEGAL NAME], Date of Birth [MM/DD/YYYY], last four digits of SSN [###-##-####], residing at [PATIENT ADDRESS] (the “Patient”).
   b. Attending Practitioner: Dr. [NAME], N.Y. License No. [#####], primary practice address [ADDRESS] (the “Attending Practitioner”).
   c. Health-Care Agent / Surrogate (if any): [NAME], relationship [RELATIONSHIP], contact [PHONE/EMAIL] (the “Agent”).

5. Recitals
   WHEREAS, the Patient, being of sound mind or represented by a duly-authorized surrogate, wishes to decline cardiopulmonary resuscitation (“CPR”) in the event of cardiac or respiratory arrest; and
   WHEREAS, the Attending Practitioner, having determined the Patient’s capacity and voluntariness, concurs with the Patient’s decision and issues the medical order reflected herein;
   NOW, THEREFORE, the Parties hereby adopt this Directive on the terms set forth below.

II. DEFINITIONS

For purposes of this Directive, capitalized terms have the meanings set forth below:

“Agent” – The individual authorized under a health-care proxy, surrogate decision-making statute, or court order to make health-care decisions for the Patient.

“Attending Practitioner” – A physician, nurse practitioner, or physician assistant licensed in New York who has primary responsibility for the Patient’s medical care and who signs this Directive.

“Cardiopulmonary Resuscitation” or “CPR” – All medical interventions intended to restore cardiac or respiratory function, including chest compressions, artificial ventilation, defibrillation, and advanced cardiac life support drugs.

“Comfort Care” – Medical or palliative measures intended to alleviate pain or discomfort but not aimed at resuscitation, including oxygen, suction, analgesics, sedation, and positioning.

“Directive” – This Out-of-Hospital Do Not Resuscitate Directive, as amended or superseded.

“EMS Provider” – Any emergency medical technician, paramedic, or other responder certified under 10 N.Y.C.R.R. Part 800.

“Good Faith” – An honest belief, without intent to deceive, and without reckless disregard for relevant facts or Governing Law.

“Out-of-Hospital Setting” – Any location other than a hospital or nursing home, including the Patient’s residence, assisted-living facility, hospice facility, or ambulance.

“Patient” – The individual named in Section I(4)(a) above.

III. OPERATIVE PROVISIONS

A. Medical Order. The Attending Practitioner hereby orders that CPR SHALL NOT BE INITIATED on the Patient in the event of cardiac or respiratory arrest. Comfort Care is expressly authorized.

B. Scope. This Directive applies in all Out-of-Hospital Settings and to all EMS Providers, healthcare professionals, and lay caregivers who may attend to the Patient.

C. Practitioner Determinations. The Attending Practitioner has determined that:
1. The Patient (or Agent) voluntarily refuses CPR after being fully informed of its nature, risks, and alternatives; and
2. The Patient either (i) possesses decision-making capacity, or (ii) lacks capacity but the Agent or surrogate is acting within statutory authority.

D. Conditions Precedent. This order shall take effect only upon actual cardiac or respiratory arrest.

E. Instructions to EMS Providers.
1. Upon presentation of an original, photocopy, or electronic image of this Directive, EMS Providers shall withhold CPR and instead provide Comfort Care consistent with local protocols.
2. If CPR has been initiated before this Directive is located, EMS Providers shall discontinue resuscitative efforts upon confirmation of a valid Directive.

F. Distribution. The Patient (or Agent) shall:
1. Maintain the original Directive in a readily accessible location;
2. Provide copies to the Agent, primary caregivers, and local EMS agency; and
3. Consider obtaining a DOH-approved DNR bracelet or pendant for immediate identification.

G. No Requirement to Withhold Other Treatment. Except for CPR, all other medically indicated treatments may be provided unless otherwise refused under a separate directive.

IV. REPRESENTATIONS & WARRANTIES

A. Patient Representations.
1. Capacity. The Patient represents that he/she/they has decision-making capacity, or that a duly-authorized Agent has executed this Directive on the Patient’s behalf.
2. Voluntariness. Execution of this Directive is voluntary and not the result of coercion or undue influence.

B. Practitioner Warranties.
1. Compliance. The Attending Practitioner warrants that he/she/they has complied with all requirements of Governing Law in issuing this order.
2. Documentation. A record of this Directive will be placed in the Patient’s medical chart within twenty-four (24) hours of execution.

C. Survival. These representations and warranties survive the revocation or expiration of this Directive to the extent necessary to protect Parties acting in Good Faith reliance hereon.

V. COVENANTS & RESTRICTIONS

A. Patient Covenant. The Patient shall promptly notify the Attending Practitioner of any change in wishes regarding resuscitation.

B. Practitioner Covenant. The Attending Practitioner shall review the continued appropriateness of this Directive during each significant change in the Patient’s medical condition and, at minimum, annually.

C. Restriction on Amendment by Third Parties. No person other than the Patient or duly-authorized Agent may amend or revoke this Directive, except as permitted under Governing Law.

VI. REVOCATION; DEFAULT & REMEDIES

A. Revocation by Patient. The Patient may revoke this Directive at any time by any of the following acts:
1. Oral or written statement of revocation;
2. Physical destruction of the Directive; or
3. Execution of a superseding DNR order or directive.

B. Revocation by Agent. An Agent may revoke only if authorized under Governing Law and subject to any express limitations in the underlying health-care proxy.

C. Effect of Revocation. Upon valid revocation, EMS Providers and other healthcare professionals shall resume full resuscitative efforts unless and until a new directive is executed.

D. Remedies for Unauthorized Resuscitation. Any party who in bad faith violates this Directive may be liable for civil damages and/or professional discipline under Governing Law. Good-faith errors are protected per Section VII.

VII. RISK ALLOCATION

A. Indemnification of Providers. The Patient (and the Patient’s estate) shall indemnify and hold harmless the Attending Practitioner, EMS Providers, and any healthcare facility or personnel acting in Good Faith reliance on this Directive from and against any claim, loss, or liability (including reasonable attorneys’ fees) arising out of withholding or discontinuing CPR pursuant to this Directive, except in cases of gross negligence or willful misconduct.

B. Limitation of Liability. In no event shall any indemnified party be liable for consequential, exemplary, or punitive damages for actions or omissions taken in Good Faith reliance on this Directive.

C. Good Faith Standard. All protections in this Section VII apply only to conduct undertaken in Good Faith and in material compliance with Governing Law.

[// GUIDANCE: New York statutes expressly provide civil and criminal immunity to practitioners and EMS personnel who act in good-faith reliance on a valid DNR order. The above contractual indemnity supplements, but does not replace, statutory immunity.]

VIII. DISPUTE RESOLUTION

A. Governing Law. This Directive shall be interpreted exclusively under the laws referenced in Section I(3).

B. Forum. Any dispute arising out of or relating to this Directive shall be brought in a court of competent jurisdiction located in the State of New York.

C. Injunctive Relief. Because the subject matter involves personal medical decision-making, the Parties acknowledge that money damages may be inadequate and that injunctive relief may be sought to enforce or prevent violation of this Directive.

D. Arbitration & Jury Waiver. Not applicable.

IX. GENERAL PROVISIONS

1. Entire Directive. This document constitutes the entire understanding concerning out-of-hospital resuscitation preferences and supersedes all prior DNR directives to the extent inconsistent.
2. Amendment. Any amendment must (i) comply with Governing Law, (ii) be in writing, and (iii) be signed and dated by the Patient (or Agent) and a licensed practitioner.
3. Severability. If any provision herein is held invalid under Governing Law, the remaining provisions shall remain in full force and effect to the maximum extent permitted.
4. Assignment. Rights and obligations under this Directive are personal to the Patient and may not be assigned.
5. Electronic Signatures. Pursuant to N.Y. State Technology Law § 304, electronic signatures are deemed valid if affixed in accordance with applicable regulations.
6. Counterparts. This Directive may be executed in multiple counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

X. EXECUTION BLOCK

[// GUIDANCE: New York does NOT require notarization of an out-of-hospital DNR, but two witnesses are recommended for evidentiary clarity and to satisfy related advance-directive statutes.]

A. Patient (or Agent) Signature

_______ _____
[PATIENT / AGENT NAME] Date
Capacity: ☐ Patient ☐ Health-Care Agent ☐ Surrogate

B. Attending Practitioner Signature

_______ _____
Dr. [NAME], [M.D./D.O./N.P./P.A.] Date
N.Y. License No.: [#####]

C. Witness Signatures

We, the undersigned, witnessed the signing of this Directive and affirm that the signatory appeared to be of sound mind and under no duress.

1. _______ _______
   [PRINT NAME & ADDRESS] Date

2. _______ _______
   [PRINT NAME & ADDRESS] Date

D. Practitioner Verification of Capacity (Optional but Recommended)

I, the Attending Practitioner, certify that on the Effective Date the Patient possessed decision-making capacity.

_______ _____
Signature Date

[// GUIDANCE:
1. Upon execution, supply a copy to the local EMS agency and affix the original in a conspicuous place (e.g., refrigerator or bedside).
2. Consider uploading the Directive to the New York State eMOLST Registry if clinically appropriate.
3. Review the Directive annually or upon any major change in health status.]