Medical Directive - DNR

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

State of Texas – Pursuant to Tex. Health & Safety Code § 166.081 et seq.

TABLE OF CONTENTS

1. Document Header
2. Definitions
3. Operative Provisions
4. Representations & Warranties
5. Covenants & Restrictions
6. Revocation & Amendment
7. Risk Allocation
8. Dispute Resolution
9. General Provisions
10. Execution Block & Witness Attestation

1. DOCUMENT HEADER

1.1 Directive Title. OUT-OF-HOSPITAL DO NOT RESUSCITATE DIRECTIVE (the “Directive”).

1.2 Parties.
(a) Patient: [PATIENT LEGAL NAME], DOB [MM/DD/YYYY], residing at [ADDRESS] (“Patient”).
(b) Attending Physician: [PHYSICIAN FULL NAME, M.D./D.O.], Texas Medical License No. [###] (“Physician”).

1.3 Effective Date. This Directive is effective on the later of (i) the date signed by Patient (or authorized representative) or (ii) the date signed by Physician (the “Effective Date”).

1.4 Governing Law. This Directive is governed exclusively by the laws of the State of Texas, including Tex. Health & Safety Code § 166.081 et seq.

2. DEFINITIONS

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

“Cardiopulmonary Resuscitation” or “CPR” means chest compressions, cardiac or external defibrillation, or any other resuscitative technique intended to restore cardiac or respiratory function.

“EMS Personnel” means licensed emergency medical services personnel, first responders, and emergency room staff acting within the scope of their certifications.

“Good-Faith Compliance” means actions undertaken in objective reliance upon the validity of this Directive and consistent with prevailing professional standards.

“Out-of-Hospital Environment” means any location outside an acute care hospital, including but not limited to an ambulatory care center, long-term care facility, hospice, private residence, or public setting.

3. OPERATIVE PROVISIONS

3.1 Directive to Withhold Resuscitative Measures. The Patient hereby directs that under no circumstances shall CPR or other advanced life-saving measures be initiated if the Patient experiences cardiac or respiratory arrest in an Out-of-Hospital Environment.

3.2 Authorization to EMS Personnel. EMS Personnel are expressly authorized and instructed to honor this Directive in accordance with Tex. Health & Safety Code § 166.087.

3.3 Provision of Comfort Care. Nothing in this Directive limits the provision of oxygen, pain relief, or any other comfort-oriented care.

3.4 Scope; Treatment Not Affected. This Directive applies solely to the initiation of resuscitative efforts and does not affect any other medical treatment decisions.

4. REPRESENTATIONS & WARRANTIES

4.1 Patient Capacity. Patient represents that he/she is of sound mind and at least 18 years of age OR is an emancipated minor under Texas law.

4.2 Voluntariness. Execution of this Directive is voluntary and made without undue influence or coercion.

4.3 Medical Counsel. Patient acknowledges having had the opportunity to confer with the Physician regarding the medical consequences of this Directive.

5. COVENANTS & RESTRICTIONS

5.1 Carry/Display Requirement. Patient covenants to maintain an easily identifiable copy of this Directive or an authorized DNR device (e.g., bracelet or necklace) on his/her person when feasible.

5.2 Notification Covenant. Patient (or the Patient’s legal representative) shall notify family members, caregivers, and health-care facilities of the existence of this Directive.

6. REVOCATION & AMENDMENT

6.1 Revocation by Patient. Patient may revoke this Directive at any time by:
(a) a signed and dated written revocation;
(b) destroying the Directive or removing an authorized DNR device; or
(c) orally expressing intent to revoke in the presence of a witness 18 years of age or older.

6.2 Automatic Revocation. This Directive is automatically revoked upon Patient’s admission to an acute care hospital unless re-executed or re-affirmed in writing at the time of admission, as permitted by law.

6.3 Amendment. Any amendment must satisfy the execution formalities of Section 10.

7. RISK ALLOCATION

7.1 Indemnification – Provider Protection. To the fullest extent permitted by law, Patient (and Patient’s estate) agrees to defend, indemnify, and hold harmless Physician, EMS Personnel, and any health-care facility or provider that honors this Directive in Good-Faith Compliance (“Indemnified Parties”) against any claim, liability, cost, or expense (including reasonable attorney fees) arising from such compliance.

7.2 Limitation of Liability. The Indemnified Parties shall not be liable for any damages beyond those caused by willful or wanton misconduct; ordinary negligence is expressly disclaimed (“Good-Faith Standard”).

8. DISPUTE RESOLUTION

Any dispute concerning the validity or interpretation of this Directive shall be submitted to a court of competent jurisdiction in the State of Texas. Nothing herein shall impair the right of any party to seek injunctive relief necessary to uphold Patient’s expressed wishes.

9. GENERAL PROVISIONS

9.1 Entire Agreement. This Directive constitutes the complete and final expression of Patient’s intent regarding out-of-hospital resuscitation and supersedes any prior inconsistent statements.

9.2 Severability. If any provision is held invalid, the remainder shall continue in full force to the maximum extent permitted by law.

9.3 Copies; Electronic Transmission. Photocopies, facsimiles, and electronically transmitted counterparts of this Directive shall be as legally effective as an original.

10. EXECUTION BLOCK & WITNESS ATTESTATION

10.1 Patient (or Authorized Representative)
Signature: _______________________________
Printed Name: ____________________________
Date: _______________

If Patient lacks capacity, complete the following:

Authorized Representative Capacity (check one):
☐ Health-Care Agent   ☐ Guardian   ☐ Close Relative   ☐ Other: ___________

10.2 Attending Physician
I, the undersigned Physician, have consulted with the Patient (or Authorized Representative) and confirm that the Patient understands—or has been adequately informed of—the medical implications of this Directive.

Physician Signature: ________________________ Date: ___________
Printed Name: _____________________________

10.3 Witnesses

Witness #1 (Disinterested)
Signature: _______________________________
Printed Name: ____________________________
Date: _______________
Address: ________________________________

Witness #2
Signature: _______________________________
Printed Name: ____________________________
Date: _______________
Address: ________________________________

10.4 Notarization (Optional but recommended for evidentiary purposes.)
State of Texas §
County of __________ §

Subscribed and sworn before me on ________________, 20____.

Notary Public Signature: ___________________________
My Commission Expires: __________________________