OUT-OF-HOSPITAL DO NOT RESUSCITATE (“DNR”) DIRECTIVE
State of Texas – Pursuant to Tex. Health & Safety Code § 166.081 et seq.
[// GUIDANCE: This template tracks the statutory “Out-of-Hospital Do Not Resuscitate Order” requirements under Texas law and is formatted for immediate attorney customization and client execution.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Revocation & Amendment
- Risk Allocation
- Dispute Resolution
- General Provisions
- 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.
[// GUIDANCE: Texas law already affords statutory civil and criminal immunity for good-faith reliance on a valid DNR; the above contractual indemnity provides an additional layer of protection.]
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
[// GUIDANCE: Dispute resolution provisions are atypical for a medical directive. The following clause preserves injunctive relief while rejecting arbitration.]
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
[// GUIDANCE: Two witnesses are REQUIRED when the Directive is executed by someone other than a competent Patient OR when executed by Physician order alone. At least one witness must be disinterested per Tex. Health & Safety Code § 166.083(c).]
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: ______
[// GUIDANCE: Attorneys should advise clients to (i) utilize the state-approved orange paper or authorized medallion device for rapid EMS recognition and (ii) file or log this Directive with the Patient’s electronic medical record.]