Do Not Resuscitate (DNR) / Comfort Care Order

DO NOT RESUSCITATE (DNR) / COMFORT CARE ORDER

State of Rhode Island

Prepared Pursuant to R.I. Gen. Laws § 23-4.11-1 et seq. (Comfort Care/DNR Act)

IMPORTANT NOTICE: This document is a medical directive that instructs emergency medical services (EMS) personnel and healthcare providers NOT to perform cardiopulmonary resuscitation (CPR) or other life-sustaining interventions in the event of cardiac or respiratory arrest. Under Rhode Island law, a Comfort Care Order must be signed by both the patient (or authorized decision-maker) AND a licensed physician or authorized healthcare provider. EMS personnel may honor this order in out-of-hospital settings only if it is properly executed and the patient displays approved Comfort Care identification (bracelet, necklace, or wallet card) pursuant to R.I. Gen. Laws § 23-4.11-9.

TABLE OF CONTENTS

1. Patient Information
2. Statutory Framework and Definitions
3. Comfort Care Order - Directive Not to Resuscitate
4. Scope of Comfort Care Measures
5. MOLST Integration
6. Authority to Consent
7. Provider Certification
8. Revocation Procedures
9. Provider Immunity and Good Faith
10. Portability and Recognition
11. Patient/Decision-Maker Acknowledgments
12. Execution Block - Patient or Authorized Decision-Maker
13. Execution Block - Licensed Healthcare Provider
14. Witness Attestations
15. Optional Notary Acknowledgment
16. Instructions for Use and Distribution
17. Comfort Care Identification

1. PATIENT INFORMATION

Emergency Contact

Health Care Agent (if appointed under R.I. Gen. Laws § 23-4.10-1 et seq.)

2. STATUTORY FRAMEWORK AND DEFINITIONS

A. Governing Law

This Comfort Care Order is governed by R.I. Gen. Laws § 23-4.11-1 et seq., known as the "Comfort Care" statute, which authorizes patients or their authorized decision-makers to direct that cardiopulmonary resuscitation and other emergency life-sustaining interventions not be performed.

B. Key Definitions (per R.I. Gen. Laws § 23-4.11-2)

"Comfort Care Order" means a medical order, signed by a licensed physician (or other authorized provider) and the patient or patient's authorized decision-maker, directing that CPR and other emergency interventions not be initiated in the event of cardiac or respiratory arrest.

"Cardiopulmonary Resuscitation (CPR)" means the administration of cardiac compression, defibrillation, endotracheal intubation, assisted ventilation, and/or the administration of cardiac resuscitation medications to restore spontaneous heart function and breathing.

"Comfort Care" means medical treatment and nursing care provided to maintain patient comfort, including but not limited to pain management, oxygen for comfort, suctioning, positioning, hygiene, wound care, and emotional support. Comfort care does NOT include CPR or other invasive life-sustaining treatment.

"Authorized Decision-Maker" means any of the following persons, in order of priority, authorized to consent to a Comfort Care Order on behalf of a patient who lacks capacity:

1. A health care agent appointed under R.I. Gen. Laws § 23-4.10-1 et seq.
2. A court-appointed guardian with authority over health care decisions
3. A spouse or domestic partner
4. An adult child
5. A parent
6. An adult sibling
7. A close friend or other person as permitted by law

"EMS Personnel" means individuals certified or licensed by the Rhode Island Department of Health to provide emergency medical services.

"Licensed Physician" means a physician licensed to practice medicine in Rhode Island under R.I. Gen. Laws Chapter 5-37.

"MOLST" means the Rhode Island Medical Orders for Life-Sustaining Treatment form, which provides a comprehensive set of medical orders regarding life-sustaining treatment preferences.

3. COMFORT CARE ORDER - DIRECTIVE NOT TO RESUSCITATE

ORDER

I, the undersigned licensed healthcare provider, hereby issue the following medical order for the patient named above:

☐ DNR - Do Not Resuscitate. In the event that the above-named patient experiences cardiac arrest (absence of pulse) or respiratory arrest (absence of breathing), cardiopulmonary resuscitation (CPR) SHALL NOT BE INITIATED. If CPR has already been initiated before this order is presented or identified, CPR shall be discontinued immediately upon verification of this order.

☐ DNR with Limited Interventions. In the event of cardiac or respiratory arrest:

• ☐ Do not perform chest compressions
• ☐ Do not perform defibrillation
• ☐ Do not perform endotracheal intubation
• ☐ Do not administer cardiac resuscitation medications
• ☐ Do provide supplemental oxygen for comfort
• ☐ Do provide bag-valve-mask ventilation (if checked)
• ☐ Other specific instructions: [________________________________]

Effective Date and Duration

This order becomes effective on the later of: (a) the date signed by the patient (or authorized decision-maker), and (b) the date signed by the licensed healthcare provider (the "Effective Date").

☐ This order remains in effect indefinitely until revoked.
☐ This order remains in effect until [__/__/____].
☐ This order remains in effect for the duration of the following condition: [________________________________]

4. SCOPE OF COMFORT CARE MEASURES

A. Comfort Care Measures to Be Provided

This DNR order does NOT prohibit the following comfort care measures, which shall continue to be provided as appropriate:

☐ Administration of oxygen for comfort and relief of dyspnea
☐ Pain management, including oral, intravenous, or subcutaneous analgesics
☐ Administration of anti-anxiety medications
☐ Suctioning of secretions for comfort
☐ Positioning for comfort and airway management
☐ Wound care and hygiene
☐ Nutrition and hydration (oral, if tolerated)
☐ Emotional, spiritual, and psychological support
☐ Hemorrhage control (pressure, bandaging)
☐ Splinting and immobilization for fractures
☐ Other comfort measures: [________________________________]

B. Measures NOT Authorized Under This Order

Unless specifically authorized above, the following interventions shall NOT be performed:

☐ Chest compressions
☐ Defibrillation (AED or manual)
☐ Endotracheal intubation
☐ Mechanical ventilation
☐ Cardiac resuscitation medications (epinephrine, atropine, vasopressin, etc.)
☐ Transcutaneous pacing
☐ Other: [________________________________]

C. Transport and Hospitalization

☐ The patient may be transported to a hospital or emergency department for conditions other than cardiac/respiratory arrest, including comfort care that cannot be provided in the current setting.
☐ The patient prefers to remain in the current location. Transport only if necessary for comfort.
☐ Other instructions regarding transport: [________________________________]

5. MOLST INTEGRATION

5.1. ☐ This Comfort Care Order is issued in conjunction with a completed Rhode Island MOLST form. The MOLST form contains additional medical orders regarding:

• Antibiotics
• Artificially administered nutrition and hydration
• Hospital transfer preferences
• Other life-sustaining treatments

5.2. ☐ No MOLST form has been completed at this time. The patient and/or decision-maker should discuss MOLST completion with the treating physician.

5.3. In the event of any conflict between this Comfort Care Order and a MOLST form, the most recently dated document shall control, unless the treating physician determines otherwise based on the patient's expressed wishes.

6. AUTHORITY TO CONSENT

A. Patient Consent

6.1. ☐ Patient has capacity. The patient is of sound mind, at least eighteen (18) years of age, and has the capacity to understand the nature, risks, benefits, and alternatives of this Comfort Care Order. The patient personally consents to this order.

B. Authorized Decision-Maker Consent (R.I. Gen. Laws § 23-4.11-4)

6.2. ☐ Patient lacks capacity. The patient currently lacks the capacity to make healthcare decisions. Consent is provided by the following authorized decision-maker:

6.3. The authorized decision-maker affirms that this order is consistent with the patient's known wishes, values, and/or advance directives, or, if the patient's wishes are unknown, that this order is in the patient's best interest.

7. PROVIDER CERTIFICATION

The undersigned licensed healthcare provider certifies that:

7.1. ☐ The patient has been informed of the medical consequences of a DNR order, including the fact that CPR will not be performed in the event of cardiac or respiratory arrest, which will likely result in death.

7.2. ☐ In the provider's good faith clinical judgment, the Comfort Care Order is medically appropriate given the patient's diagnosis, prognosis, and expressed wishes.

7.3. ☐ The provider has discussed with the patient (or authorized decision-maker):

• The patient's current medical condition and prognosis
• The nature of CPR and its likelihood of success given the patient's condition
• The risks and burdens of CPR
• Alternatives, including comfort care and palliative care
• The patient's goals of care

7.4. ☐ The provider is licensed to practice medicine in Rhode Island and is authorized to issue this order under R.I. Gen. Laws § 23-4.11-3.

7.5. Patient's Diagnosis/Condition: [________________________________]

7.6. Prognosis: [________________________________]

8. REVOCATION PROCEDURES

Revocation Under R.I. Gen. Laws § 23-4.11-6

This Comfort Care Order may be revoked at any time by any of the following methods:

8.1. Written Revocation. The patient (or authorized decision-maker) signs and dates a written statement revoking this order.

8.2. Oral Revocation. The patient (or authorized decision-maker) makes an oral statement of intent to revoke in the presence of a healthcare provider or EMS personnel.

8.3. Physical Destruction. The patient physically destroys the original Comfort Care Order document and any Comfort Care identification.

8.4. Revocation by Provider. A licensed physician may revoke or modify this order at the request of the patient or authorized decision-maker.

8.5. Effective Immediately. Revocation is effective immediately upon communication to medical personnel. Upon revocation, full resuscitative measures shall be provided as clinically indicated.

8.6. Documentation. Upon revocation, the revoking party or provider should:
☐ Notify all healthcare providers involved in the patient's care
☐ Remove or destroy Comfort Care identification (bracelet, necklace, wallet card)
☐ Document the revocation in the patient's medical record
☐ Retrieve and destroy copies of this order from care facilities

9. PROVIDER IMMUNITY AND GOOD FAITH

9.1. Immunity for Compliance. Under R.I. Gen. Laws § 23-4.11-5, no healthcare provider or EMS personnel shall be subject to civil liability, criminal prosecution, or professional discipline for:

• Honoring this Comfort Care Order in good faith
• Withholding or withdrawing CPR in accordance with this order
• Providing comfort care in accordance with this order

9.2. Immunity for Good-Faith Reliance. No healthcare provider or EMS personnel shall be liable for providing CPR in good faith reliance on a revocation of this order or the absence of a properly executed Comfort Care Order or identification.

9.3. No Requirement to Participate. A healthcare provider who objects to honoring this order on moral or ethical grounds shall promptly transfer the patient's care to a provider willing to honor the order.

9.4. Patient/Estate Indemnification. The patient (and the patient's estate) agrees to indemnify and hold harmless healthcare providers and EMS personnel from any civil liability, claim, or expense arising out of good faith compliance with or reliance upon this Comfort Care Order.

10. PORTABILITY AND RECOGNITION

10.1. Within Rhode Island. This Comfort Care Order shall be honored by all healthcare providers and EMS personnel within the State of Rhode Island when properly executed and accompanied by approved Comfort Care identification.

10.2. Copies. A legible photocopy, facsimile, or electronic copy of this order has the same legal effect as the original, pursuant to R.I. Gen. Laws § 23-4.11-3.

10.3. Out of State. Patients who travel outside Rhode Island should be aware that other states may not recognize this order. Patients are encouraged to obtain a portable DNR order valid in the destination state.

10.4. Facility Transfers. When the patient is transferred between care settings (e.g., home to nursing facility, nursing facility to hospital), this order shall accompany the patient and be communicated to the receiving facility.

11. PATIENT/DECISION-MAKER ACKNOWLEDGMENTS

By initialing below, the patient (or authorized decision-maker) acknowledges:

Initials: [____] I understand that this order directs that CPR will NOT be performed if my heart stops or I stop breathing, and that this will likely result in my death.

Initials: [____] I understand the difference between comfort care and life-sustaining treatment.

Initials: [____] I have discussed this decision with my healthcare provider and understand my diagnosis and prognosis.

Initials: [____] I understand that I may revoke this order at any time by written statement, oral statement, or physical destruction of the document.

Initials: [____] I understand that I should obtain and wear Comfort Care identification (bracelet, necklace, or wallet card) so that EMS personnel can identify and honor this order.

Initials: [____] I understand that this order applies to EMS and all healthcare settings within Rhode Island.

Initials: [____] I have been offered the opportunity to discuss my wishes with family members, spiritual advisors, and other support persons.

Initials: [____] I execute this order voluntarily, without duress or coercion.

12. EXECUTION BLOCK - PATIENT OR AUTHORIZED DECISION-MAKER

Patient Signature (if patient has capacity)

Signature: _____________________________________________

Printed Name: [________________________________]

Date: [__/__/____]

Authorized Decision-Maker Signature (if patient lacks capacity)

Signature: _____________________________________________

Printed Name: [________________________________]

Relationship to Patient: [________________________________]

Authority (DPOA-HC, Guardian, etc.): [________________________________]

Date: [__/__/____]

13. EXECUTION BLOCK - LICENSED HEALTHCARE PROVIDER

I, the undersigned, hereby issue this medical order directing that no cardiopulmonary resuscitation be administered to the above-named patient in the event of cardiac or respiratory arrest, consistent with R.I. Gen. Laws § 23-4.11-1 et seq.

Signature: _____________________________________________

Printed Name: [________________________________]

Title: ☐ MD ☐ DO ☐ APRN ☐ PA ☐ Other: [________________________________]

Rhode Island License Number: [________________________________]

NPI Number: [________________________________]

Practice/Facility: [________________________________]

Telephone: [________________________________]

Date: [__/__/____]

14. WITNESS ATTESTATIONS

Each witness declares under penalty of perjury that: (i) the patient (or authorized decision-maker) appeared to execute this Comfort Care Order voluntarily and with capacity; (ii) the witness meets all requirements of a qualified witness; and (iii) the witness is not a healthcare provider directly involved in the patient's care.

Witness Requirements Under Rhode Island Law:

• At least eighteen (18) years of age
• Not related to the patient by blood, marriage, or adoption
• Not entitled to any portion of the patient's estate
• Not directly involved in the patient's medical care or facility administration

Witness 1

Witness 2

15. OPTIONAL NOTARY ACKNOWLEDGMENT

State of Rhode Island )
) SS:
County of [________________________________] )

On [__/__/____], before me, [________________________________], a Notary Public in and for the State of Rhode Island, personally appeared [________________________________], proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the foregoing instrument, and acknowledged that they executed the same in their authorized capacity.

Notary Signature: _____________________________________________

Printed Name: [________________________________]

My Commission Expires: [__/__/____]

[NOTARIAL SEAL]

16. INSTRUCTIONS FOR USE AND DISTRIBUTION

Distribution of Copies

Upon execution, copies of this Comfort Care Order should be provided to:

☐ Patient (original or copy for home, posted in a visible location)
☐ Patient's medical record (primary care physician)
☐ Hospital or care facility medical record
☐ Home health agency (if applicable)
☐ Hospice provider (if applicable)
☐ Health care agent or authorized decision-maker
☐ Family members designated by the patient
☐ Rhode Island Health Information Exchange (CurrentCare), if available

Posting and Accessibility

☐ Post a copy of this order on or near the patient's bed (in a care facility)
☐ Post a copy on the refrigerator or inside the front door (at home), per EMS protocol
☐ Keep a wallet-sized copy with patient identification
☐ Upload to electronic health record system

17. COMFORT CARE IDENTIFICATION

Rhode Island Comfort Care Identification (R.I. Gen. Laws § 23-4.11-9)

For EMS personnel to honor this order in out-of-hospital settings, the patient should obtain and display approved Comfort Care identification:

☐ Comfort Care Bracelet - Ordered through the patient's physician or healthcare facility
☐ Comfort Care Necklace - Alternative wearable identification
☐ Comfort Care Wallet Card - Carried in the patient's wallet or purse

The identification should include:

• The words "COMFORT CARE" or "DNR"
• The patient's name
• The physician's name and contact information
• The date the order was issued

How to Obtain Comfort Care Identification

Contact:

• The patient's primary care physician
• The Rhode Island Department of Health
• The patient's healthcare facility or hospice provider

PRACTICE NOTES FOR RHODE ISLAND PRACTITIONERS

Rhode Island Comfort Care Act Overview

• R.I. Gen. Laws § 23-4.11-1 et seq. provides the statutory framework for out-of-hospital DNR orders
• The statute requires BOTH patient (or decision-maker) consent AND physician authorization
• Two qualified witnesses are required
• Comfort Care identification is critical for EMS recognition in community settings

MOLST in Rhode Island

• The Rhode Island MOLST program provides a standardized form for medical orders regarding life-sustaining treatment
• MOLST covers a broader range of treatment decisions beyond DNR (antibiotics, nutrition, hospitalization)
• MOLST is a complement to, not a replacement for, a Comfort Care Order
• MOLST forms are available through the Rhode Island Department of Health

Distinction from Living Will / Health Care Power of Attorney

• A Comfort Care Order is a MEDICAL ORDER signed by a physician, not merely a directive
• A Living Will under R.I. Gen. Laws § 23-4.11 expresses wishes but may not be honored by EMS without a physician order
• A Health Care Power of Attorney (R.I. Gen. Laws § 23-4.10) designates a decision-maker but does not itself constitute a DNR order

EMS Protocol

• Rhode Island EMS personnel are trained to look for Comfort Care identification
• Without proper identification or documentation, EMS will initiate full resuscitation
• EMS may contact medical control for guidance if the validity of a DNR order is in question

SOURCES AND REFERENCES

1. R.I. Gen. Laws § 23-4.11-1 - Short title; Comfort Care Act
2. R.I. Gen. Laws § 23-4.11-2 - Definitions
3. R.I. Gen. Laws § 23-4.11-3 - Comfort care order; form and execution
4. R.I. Gen. Laws § 23-4.11-4 - Consent; who may authorize comfort care order
5. R.I. Gen. Laws § 23-4.11-5 - Immunity from liability for providers and EMS
6. R.I. Gen. Laws § 23-4.11-6 - Revocation of comfort care order
7. R.I. Gen. Laws § 23-4.11-9 - Comfort care identification (bracelet, necklace, card)
8. R.I. Gen. Laws § 23-4.10-1 et seq. - Health Care Power of Attorney Act
9. R.I. Gen. Laws § 23-4.10-2 - Durable power of attorney for health care
10. R.I. Gen. Laws § 5-37-1 et seq. - Physician licensing
11. Rhode Island MOLST Program - Rhode Island Department of Health
12. Rhode Island EMS Protocols - Division of Emergency Medical Services, RI DOH
13. National POLST Paradigm - https://polst.org/ (Rhode Island is a POLST-participating state)
14. Pawtucket Memorial Hospital v. Rhode Island Health Services Council - Recognition of patient autonomy in treatment decisions

This template is provided for informational and educational purposes only. It does not constitute legal or medical advice. Rhode Island law regarding advance directives and comfort care orders is subject to periodic revision. Always verify current statutory text and consult with a qualified Rhode Island-licensed attorney and healthcare provider before execution. Use of this template does not create an attorney-client or physician-patient relationship. For the official Rhode Island Comfort Care Order form, contact the Rhode Island Department of Health.