PENNSYLVANIA OUT-OF-HOSPITAL
DO NOT RESUSCITATE (“DNR”) ORDER & MEDICAL DIRECTIVE
[// GUIDANCE: This template is intended for use by licensed Pennsylvania attorneys and qualified health-care professionals. Review all statutory requirements, local hospital policies, and EMS protocols before customization. Remove all guidance boxes prior to final execution.]
I. DOCUMENT HEADER
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Parties
1.1 Patient: [PATIENT LEGAL NAME] (“Patient”)
1.2 Attending/Ordering Physician: [PHYSICIAN NAME], M.D./D.O., Pennsylvania License No. [LICENSE #] (“Physician”)
1.3 Health-Care Providers & Emergency Medical Services Personnel (collectively, “Providers”): Any individual or entity that may provide medical care or pre-hospital emergency services to Patient within the Commonwealth of Pennsylvania. -
Recitals
A. Patient desires to exercise the right to refuse cardiopulmonary resuscitation (“CPR”) and any advanced cardiac life support (“ACLS”) measures in the event Patient experiences cardiac or respiratory arrest outside a hospital setting.
B. Pennsylvania law recognizes the validity and enforceability of out-of-hospital DNR orders when executed in compliance with state requirements.
C. Physician has determined that Patient (i) possesses decision-making capacity or Patient’s legally authorized representative (“Surrogate”) has such authority, and (ii) has been fully informed of the medical implications of a DNR order.
D. The Parties intend this Directive to constitute a legally binding medical order that Providers shall honor in good faith. -
Effective Date & Governing Law
3.1 This Directive is effective on the date of last signature below (“Effective Date”).
3.2 This Directive is governed by the health-care laws of the Commonwealth of Pennsylvania (“PA Law”).
II. DEFINITIONS
For purposes of this Directive, capitalized terms have the meanings set forth below:
“Advance Directive” – A written instruction such as a living will or health-care power of attorney recognized under PA Law, expressing Patient’s health-care choices.
“Cardiopulmonary Resuscitation (CPR)” – Chest compressions, defibrillation, artificial ventilation, endotracheal intubation, administration of ACLS drugs, and any other life-sustaining interventions intended to revive spontaneous cardiac or respiratory function.
“EMS” – Any certified Pennsylvania Emergency Medical Services personnel or agency responding to a call for assistance involving Patient.
“Good Faith” – An honest belief, without malice or the intent to defy applicable law or this Directive, that the action taken is appropriate under the circumstances.
“Surrogate” – An individual authorized under PA Law to make health-care decisions on behalf of Patient, including a health-care agent, guardian, or next of kin as applicable.
III. OPERATIVE PROVISIONS
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DNR Order
4.1 Order to Withhold Resuscitative Measures. In the event Patient suffers cardiac or respiratory arrest at any location outside an acute-care hospital, Providers shall not initiate or continue CPR or ACLS.
4.2 Permitted Palliative Care. Providers shall render comfort-focused treatment (e.g., oxygen for symptom relief, pain management, hemorrhage control) consistent with standard medical practice.
4.3 Transfer & Hospitalization. This Directive does not prohibit transport or admission where medically appropriate for non-resuscitative treatment. -
EMS Recognition Requirements
5.1 Patient (or Surrogate) shall present one of the following at the scene:
(a) The original or a photocopy of this Directive;
(b) A Pennsylvania-approved DNR bracelet or necklace; or
(c) A Pennsylvania Department of Health (“DOH”)-issued DNR wallet card.
5.2 EMS personnel acting in Good Faith reliance on any item in § 5.1 are immune from civil or criminal liability to the fullest extent permitted under PA Law. -
Revocation
6.1 Patient (or Surrogate) may revoke this Directive at any time by:
(a) A signed and dated written revocation;
(b) An oral statement in the presence of two adult witnesses; or
(c) Physically destroying the DNR document, bracelet, or necklace with the intent to revoke.
6.2 Upon revocation, Patient (or Surrogate) shall promptly notify Physician and Providers. -
Duration & Review
7.1 This Directive remains in effect unless revoked pursuant to § 6.
7.2 Physician shall review Patient’s wishes periodically, and at minimum upon:
(a) Significant change in Patient’s health status;
(b) Transfer to or from a health-care facility; or
(c) Patient’s request.
IV. REPRESENTATIONS & WARRANTIES
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Patient / Surrogate Representations
8.1 Patient possesses decisional capacity or Surrogate is duly authorized under valid Advance Directive or applicable statute.
8.2 Patient/Surrogate has had the opportunity to ask questions and understands the consequences of a DNR order. -
Physician Representations
9.1 Physician is duly licensed in Pennsylvania and personally examined Patient.
9.2 Physician has discussed prognosis, treatment alternatives, and likely outcomes with Patient/Surrogate and believes execution of this Directive is voluntary and informed.
V. COVENANTS & RESTRICTIONS
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Notification & Documentation
10.1 Patient/Surrogate shall provide copies of this Directive to:
(a) Each of Patient’s treating facilities;
(b) Known health-care agents; and
(c) Close family members as appropriate.
10.2 Physician shall enter this Directive into Patient’s medical record and, when feasible, into any applicable electronic medical record (“EMR”) exchange. -
Non-Interference
Providers shall not delay or withhold palliative care while verifying the validity of this Directive.
VI. DEFAULT & REMEDIES
[// GUIDANCE: Because a DNR is a unilateral medical order rather than a bilateral contract, “default” is framed in terms of noncompliance.]
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Event of Noncompliance
Failure by any Provider to honor this Directive constitutes a breach of duties under PA Law and professional licensing standards. -
Cure & Reporting
13.1 Upon discovery of a breach, Patient/Surrogate may file a complaint with:
(a) The Pennsylvania DOH Bureau of EMS; or
(b) The appropriate professional licensing board.
13.2 Providers shall cooperate in any investigation and implement corrective measures. -
Injunctive Relief
Patient/Surrogate is entitled to equitable relief, including specific performance, to enforce the terms of this Directive without posting bond.
VII. RISK ALLOCATION
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Provider Immunity & Indemnification
15.1 Providers acting in Good Faith compliance with this Directive are immune from liability to the maximum extent permitted under PA Law.
15.2 Patient, Surrogate, and Patient’s estate shall indemnify and hold harmless Providers from any claim arising out of Good Faith reliance on this Directive, except in cases of gross negligence or willful misconduct. -
Limitation of Liability
Any damages recoverable against Providers are limited to direct damages proximately caused by gross negligence or willful misconduct; consequential, incidental, or punitive damages are disclaimed.
VIII. DISPUTE RESOLUTION
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Governing Law
This Directive and any dispute arising hereunder shall be construed in accordance with PA Law, without regard to conflict-of-law rules. -
Forum
Any legal action shall be brought exclusively in the Court of Common Pleas of the county in which Patient resides at the time of filing. -
Jury Waiver
NOT APPLICABLE. (Intentionally omitted in accordance with metadata.) -
Arbitration
NOT APPLICABLE. (Intentionally omitted in accordance with metadata.)
IX. GENERAL PROVISIONS
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Amendment
This Directive may be amended only by executing a new Pennsylvania-compliant DNR order. -
Severability
If any provision of this Directive is held invalid, the remaining provisions shall remain in full force and effect to the greatest extent possible. -
Integration
This Directive supersedes all prior DNR orders executed in Pennsylvania by or on behalf of Patient. -
Copies & Electronic Signatures
24.1 Photocopies and facsimiles of this Directive are as valid as the original.
24.2 Electronic signatures compliant with the Pennsylvania Uniform Electronic Transactions Act are acceptable, except that the Physician signature must be handwritten if required by current DOH regulations.
X. EXECUTION BLOCK
[// GUIDANCE: Pennsylvania regulations currently require the Physician’s handwritten signature. Confirm whether remote or electronic notarization is permissible at the time of execution.]
A. PATIENT OR SURROGATE
| Signature | Printed Name | Date | Relationship (if Surrogate) |
|---|---|---|---|
| ________ | ________ | ____ | ______ |
B. WITNESSES (Two adult witnesses recommended)
| Witness # | Signature | Printed Name | Date |
|---|---|---|---|
| 1 | ________ | ________ | ____ |
| 2 | ________ | ________ | ____ |
C. PHYSICIAN ORDER
“I, the undersigned licensed physician, hereby issue this Out-of-Hospital Do Not Resuscitate Order in accordance with Pennsylvania law.”
| Signature (Handwritten) | Printed Name | Date | PA Medical License # | Phone |
|---|---|---|---|---|
| ______ | ______ | ____ | ____ | ____ |
[Seal/Stamp (if any): ______]
OPTIONAL ATTACHMENTS
- Copy of Patient’s Advance Directive or Health-Care Power of Attorney.
- DOH-approved DNR wallet card or bracelet order form.
[// GUIDANCE: End of template. Remove all guidance comments before finalization.]