TENNESSEE DO NOT RESUSCITATE (“DNR”) DIRECTIVE

and Emergency Medical Services (“EMS”) Non-Resuscitation Order

[// GUIDANCE: This document combines (i) the patient’s advance directive instructing that cardiopulmonary resuscitation (“CPR”) and other advanced life-support measures are to be withheld, and (ii) the statutorily-recognized EMS DNR Order required for out-of-hospital enforcement in Tennessee. It is drafted to satisfy Tenn. Code Ann. § 68-11-224 and the Tennessee Health Care Decisions Act, Tenn. Code Ann. § 68-11-1801 et seq. Practitioners should append any Department of Health–issued “POST” or successor form if locally required and confirm the most current Department regulations before execution.]

TABLE OF CONTENTS

I. Document Header
II. Definitions
III. Operative Provisions
IV. Representations & Warranties
V. Covenants & Restrictions
VI. Default & Remedies
VII. Risk Allocation
VIII. Dispute Resolution
IX. General Provisions
X. Execution Block

I. DOCUMENT HEADER

1. Title. Tennessee Do Not Resuscitate (“DNR”) Directive and EMS Non-Resuscitation Order.
2. Parties.
   a. Patient: [PATIENT LEGAL NAME], DOB [MM/DD/YYYY], SSN [LAST 4];
   b. Authorized Agent (if any): [AGENT NAME OR “N/A”];
   c. Attending Physician/Advanced Practice Provider: [PROVIDER NAME & CREDENTIALS], TN Lic. No. [____].
3. Recitals.
   a. Patient possesses decisional capacity (or Agent is duly authorized) and desires to forego CPR and advanced life-support interventions.
   b. Tennessee law recognizes a patient’s right to refuse such treatment and provides legal immunity to good-faith-complying providers.
4. Consideration. Mutual promises herein are deemed sufficient consideration.
5. Effective Date. [EFFECTIVE DATE (MM/DD/YYYY)].
6. Governing Law. State of Tennessee health-care law.

II. DEFINITIONS

“Advanced Life-Support Measures” – defibrillation, endotracheal intubation, mechanical ventilation, administration of cardiotonic drugs, or any comparable resuscitative intervention.

“Agent” – The individual authorized to make health-care decisions for Patient under a valid health-care power of attorney or as surrogate under Tenn. Code Ann. § 68-11-1806.

“CPR” – Cardiopulmonary resuscitation, including chest compressions and/or artificial respiration.

“Directive” – This Tennessee DNR Directive and EMS Order, together with any duly executed POST form.

“EMS Personnel” – Emergency medical technicians, paramedics, first responders, or other out-of-hospital providers licensed under Tenn. Code Ann. Title 68, Ch. 140.

“Good Faith” – Honesty in fact and the reasonable belief that the action taken is consistent with applicable standards of medical practice.

“Health-Care Provider” – Any individual or facility licensed, certified, or otherwise authorized to provide medical services in Tennessee.

“Revocation” – Verbal or written expression by Patient (or Agent if Patient lacks capacity) that the Directive is withdrawn.

III. OPERATIVE PROVISIONS

1. Directive to Withhold Resuscitation.
   Patient hereby instructs that no CPR or Advanced Life-Support Measures shall be initiated or continued in the event of cardiac or respiratory arrest.

2. EMS Enforcement.
   a. This Directive constitutes a valid “Do Not Resuscitate Order for EMS” under Tenn. Code Ann. § 68-11-224.
   b. EMS Personnel presented with the original, a legible copy, or a state-approved identification (e.g., DNR bracelet/tag) shall honor the order and provide comfort-care only.

3. Hospital & Facility Enforcement.
   Upon admission, Patient (or Agent) shall deliver a copy to the admitting facility, which shall enter a DNR order into the medical record without delay.

4. Comfort-Care Measures.
   Nothing herein restricts the provision of oxygen, pain management, or other palliative interventions designed solely for comfort.

5. Transfer of Care.
   If a provider is unwilling to comply, provider shall arrange prompt transfer in accordance with Tenn. Code Ann. § 68-11-1807.

6. Revocation.
   a. Patient may revoke at any time by oral or written statement or by destroying all executed originals.
   b. Revocation is effective upon communication to any Health-Care Provider.

7. Duration.
   This Directive remains in force until revoked or superseded by a later-dated document expressly modifying these instructions.

IV. REPRESENTATIONS & WARRANTIES

1. Capacity. Patient represents that they are of sound mind and at least eighteen (18) years old or legally emancipated.
2. Voluntariness. Execution is voluntary and free from coercion or undue influence.
3. Provider Warranty. Attending Physician/Provider warrants that the medical prognosis has been discussed with Patient/Agent and that in their judgment resuscitative efforts would be medically inappropriate or contrary to Patient’s wishes.
4. Survival. The warranties in this Section survive revocation only to the extent necessary to protect Providers who acted in Good Faith reliance prior to actual notice of revocation.

V. COVENANTS & RESTRICTIONS

1. Patient/Agent Covenant to Notify. Patient or Agent shall notify subsequent Health-Care Providers of this Directive’s existence.
2. Provider Covenant of Documentation. Providers shall document in the medical record each time reliance is placed on this Directive.
3. Restriction on Alteration. No alteration is permitted after execution other than complete revocation and re-execution; partial edits are void.

VI. DEFAULT & REMEDIES

1. Event of Default. Initiation of CPR in contravention of this Directive constitutes a default.
2. Notice & Cure. Because resuscitation is instantaneous, cure is not feasible; however, Providers shall cease resuscitative efforts immediately upon discovering the Directive.
3. Remedies.
   a. Patient (or Estate) may pursue remedies available under law, subject to the liability limitations in Section VII.
   b. Providers acting in Good Faith are immune from civil/criminal liability per Tenn. Code Ann. § 68-11-224(d).

VII. RISK ALLOCATION

1. Indemnification (Provider Protection).
   Patient and their Estate agree to hold harmless and indemnify any Health-Care Provider or EMS Personnel who, in Good Faith, withhold or withdraw resuscitation consistent with this Directive.

2. Limitation of Liability (Good-Faith Standard).
   No Provider shall be liable for damages, civil or criminal, or subject to disciplinary action when acting in Good Faith reliance on this Directive or for failing to act upon reasonable doubt respecting its validity.

3. Insurance. Patient acknowledges that some insurance benefits may be conditioned upon life-saving interventions and accepts the risk of reduced coverage.

4. Force Majeure. Performance is excused to the extent compliance is impossible due to natural disaster or mass-casualty incident rendering recognition impracticable.

VIII. DISPUTE RESOLUTION

1. Governing Law. This Directive is governed exclusively by the laws of the State of Tennessee.
2. Forum Selection / Arbitration / Jury Waiver. Not applicable to this Directive.
3. Injunctive Relief. Any court of competent jurisdiction may issue equitable relief to enforce or prevent violation of this Directive.

IX. GENERAL PROVISIONS

1. Amendment & Waiver. May be amended only by a new written instrument executed with the formalities of this Directive.
2. Assignment. Rights and obligations are personal to Patient and may not be assigned.
3. Successors & Assigns. Binding upon Patient’s heirs, executors, administrators, and legal representatives.
4. Severability. If any provision is invalid, the remainder shall be enforced to the fullest extent permitted.
5. Integration. This Directive constitutes the entire agreement regarding resuscitation preferences and supersedes inconsistent prior statements.
6. Electronic Copies. Photocopies, facsimile, or electronically stored copies bearing authentic signatures are as effective as originals.

X. EXECUTION BLOCK

[// GUIDANCE: Tennessee permits EITHER two qualified witnesses OR notarization. Witnesses must be adults who are not (i) related by blood, marriage, or adoption, (ii) entitled to any portion of the patient’s estate, or (iii) directly financially responsible for the patient’s health care.]

1. PATIENT (or AGENT) SIGNATURE

I, the undersigned Patient (or duly authorized Agent), affirm that I have read, understand, and voluntarily execute this Directive.

Signature: ____ Date: __
Printed Name: ____ Relationship (if Agent): __

2. ATTENDING PHYSICIAN / ADVANCED PRACTICE PROVIDER

I affirm that the foregoing instructions are medically appropriate and that I have discussed alternatives and consequences with the Patient or Agent.

Signature: ____ Date: __
Printed Name & Credentials: ____ TN Lic. No.: ___
Practice Address & Phone: _________

3. OPTIONAL EMS DNR IDENTIFIER

☐ Patient has been issued a Tennessee-approved DNR bracelet/tag bearing ID No. [______].

4. WITNESS ATTESTATION (Use TWO witnesses OR notarization)

We declare under penalty of perjury that (i) the Patient/Agent signed or acknowledged this Directive in our presence, (ii) the Patient appears to be of sound mind and free from duress, and (iii) we are qualified witnesses under Tennessee law.

5. NOTARY ACKNOWLEDGMENT (Complete ONLY if witnesses are not used)

State of Tennessee )
County of ____)

On this ___ day of _, 20_, before me, ____, a Notary Public in and for said State, personally appeared ________, personally known to me (or proved to me on the basis of satisfactory evidence) to be the individual whose name is subscribed to the within instrument and acknowledged that they executed the same for the purposes therein contained.

IN WITNESS WHEREOF I hereunto set my hand and official seal.

Notary Public Signature: _____
My Commission Expires: ______ (SEAL)

[// GUIDANCE:
1. Retain the original with the Patient; place copies in all relevant medical records; give copies to family and Agent.
2. Advise Patient to carry wallet-sized notice or wear state-approved bracelet for EMS recognition.
3. Review annually or upon any substantial change in health status or personal wishes.
4. If converting to a POST form, replicate the substantive choices herein verbatim or attach this Directive as an addendum.]