UTAH OUT-OF-HOSPITAL DO NOT RESUSCITATE DIRECTIVE

(Comprehensive Template – Court-Ready Draft)

[// GUIDANCE: This template is structured for immediate attorney customization and clinical execution. It integrates Utah-specific statutory requirements for EMS recognition, witness formalities, and provider protections while employing defensive drafting techniques to minimize liability exposure.]

TABLE OF CONTENTS

1. Document Header
2. Definitions
3. Operative Provisions
4. Representations & Warranties
5. Covenants & Restrictions
6. Default, Revocation & Remedies
7. Risk Allocation
8. Dispute Resolution
9. General Provisions
10. Execution Block (Signature Pages & Witness/Notary Certification)

1. DOCUMENT HEADER

1.1 Title

Out-of-Hospital Do Not Resuscitate Directive (Utah)

1.2 Parties

a. “Principal”: [PRINCIPAL LEGAL NAME], an individual of full legal capacity and at least eighteen (18) years of age, residing at [ADDRESS].
b. “Authorized Health-Care Provider”: [PROVIDER NAME & CREDENTIALS], licensed in the State of Utah.
c. “Health-Care Agent” (optional): [AGENT NAME], designated under a duly-executed Utah Advance Health Care Directive.

1.3 Effective Date

This Directive becomes effective on the latest date of signature in Section 10 (Execution Block) (the “Effective Date”).

1.4 Governing Law

This Directive shall be construed in accordance with the healthcare laws, regulations, and public-policy pronouncements of the State of Utah (“State Health-Care Law”).

2. DEFINITIONS

For purposes of this Directive, the following capitalized terms shall have the meanings set forth below. Undefined capitalized terms shall have the meanings ascribed to them by applicable State Health-Care Law.

“Cardiopulmonary Resuscitation” or “CPR” means chest compressions, defibrillation, manual ventilation, advanced airway management, administration of cardiac medications, and any other medical intervention intended to restore cardiac or respiratory function.

“DNRO” means this duly executed Out-of-Hospital Do Not Resuscitate Order/Directive.

“EMS” means emergency medical services personnel, including but not limited to paramedics, emergency medical technicians, and first responders licensed or certified in the State of Utah.

“Good-Faith Compliance” means compliance by any Provider or EMS personnel with the DNRO, absent gross negligence or willful misconduct.

“Life-Sustaining Treatment” means any medical procedure or intervention which serves only to postpone the moment of death and where, in the judgment of the Authorized Health-Care Provider, death is imminent if such treatment is withheld.

“Principal” has the meaning given in Section 1.2(a).

“Provider” means any individual or facility licensed, certified, or otherwise authorized to provide medical care in Utah, including hospitals, long-term care facilities, clinics, and EMS.

3. OPERATIVE PROVISIONS

3.1 Directive Not to Resuscitate

The Principal hereby DIRECTS that, in the event of respiratory or cardiac arrest, NO Cardiopulmonary Resuscitation or other advanced cardiac life support SHALL BE ATTEMPTED. All EMS personnel and Providers SHALL:
1. Provide comfort-focused palliative care only; and
2. Refrain from initiating or continuing any Life-Sustaining Treatment aimed at resuscitation.

3.2 Scope of Directive

This DNRO applies in ALL out-of-hospital settings, including but not limited to the Principal’s residence, nursing facilities, ambulances, and other non-hospital locations within Utah.

3.3 Exceptions

Nothing herein prohibits:
a. Pain management, hydration for comfort, or other palliative measures;
b. The Principal or duly-appointed surrogate (e.g., Health-Care Agent) from revoking or modifying this DNRO pursuant to Section 6; or
c. EMS from transporting the Principal to a hospital when medically appropriate and not inconsistent with the foregoing directives.

3.4 Documentation & Presentation Requirements

a. The Original DNRO (or a Designated Copy) shall accompany the Principal at all times.
b. A wallet card, bracelet, or necklace bearing conspicuous “UT DNR” language is recommended for rapid EMS verification.
c. Providers shall retain a copy in the Principal’s medical record and, upon transfer, ensure the DNRO travels with the Principal.

[// GUIDANCE: Utah EMS protocols currently recognize the state-promulgated “POLST/DNR” form printed on bright PINK paper for rapid visibility. Attorneys should confirm color/form requirements remain current.]

4. REPRESENTATIONS & WARRANTIES

4.1 By Principal
a. Capacity & Voluntariness: The Principal represents that they are of sound mind, acting voluntarily, and not under duress or undue influence.
b. Understanding of Consequences: The Principal acknowledges full understanding that CPR and advanced cardiac life support will be withheld.

4.2 By Authorized Health-Care Provider
The Provider represents that:
a. The Principal has been counseled regarding prognosis, resuscitation outcomes, and palliative options; and
b. The Provider finds the DNRO medically appropriate and consistent with the Principal’s wishes.

4.3 Survival
All representations in this Section shall survive execution of the DNRO and any treatment decisions predicated thereon.

5. COVENANTS & RESTRICTIONS

5.1 Principal Covenants
a. Notification: The Principal shall inform all subsequent Providers of the existence of this DNRO.
b. Updates: The Principal shall execute a new DNRO if any material change in wishes or legal requirements occurs.

5.2 Provider Covenants
Providers covenant to:
a. Honor this DNRO in Good-Faith Compliance;
b. Communicate the DNRO’s existence to EMS and receiving facilities upon transfer; and
c. Document all DNRO-related actions in the Principal’s medical record.

6. DEFAULT, REVOCATION & REMEDIES

6.1 Revocation by Principal
The Principal or an authorized surrogate may revoke this DNRO at ANY time by:
a. Verbally expressing the intent to revoke in the presence of a Provider or EMS personnel;
b. Physically destroying the DNRO form and all copies; OR
c. Executing a superseding written directive.

6.2 Automatic Suspension
This DNRO is suspended during surgical or other procedures performed under general anesthesia when, in the opinion of the attending surgeon or anesthesiologist, temporary suspension is required. Suspension automatically terminates upon completion of such procedure.

6.3 Remedies
Providers or EMS acting contrary to this DNRO—absent valid revocation—may be subject to administrative, civil, or criminal liability under State Health-Care Law.

7. RISK ALLOCATION

7.1 Indemnification (Provider Protection)
The Principal (and Principal’s estate) agrees to RELEASE AND HOLD HARMLESS any Provider, EMS agency, or individual acting in Good-Faith Compliance with this DNRO from any and all liability, claims, or causes of action arising out of such compliance.

7.2 Limitation of Liability
No Provider or EMS personnel shall be liable for damages, civil or criminal, for either complying with or, after reasonable inquiry, declining to comply with a DNRO that appears altered, forged, or revoked; provided they act in good faith and in accordance with professional standards (the “Good-Faith Standard”).

8. DISPUTE RESOLUTION

8.1 Governing Law
All disputes arising under or relating to this DNRO shall be governed by the internal laws of the State of Utah.

8.2 Injunctive Relief
Because the subject matter involves personal bodily integrity and imminent medical decision-making, the parties acknowledge that monetary damages are an inadequate remedy. Courts of competent jurisdiction within Utah may grant temporary, preliminary, and/or permanent injunctive relief to enforce or enjoin actions inconsistent with this DNRO.

[// GUIDANCE: Arbitration, jury waiver, and forum-selection clauses are intentionally omitted as incompatible with emergency medical enforcement contexts.]

9. GENERAL PROVISIONS

9.1 Amendment
This DNRO may be amended only by a written instrument executed with the same formalities as this DNRO.

9.2 Assignment
Rights and obligations hereunder are unique to the Principal and may not be assigned.

9.3 Severability
If any provision is held unenforceable, the remaining provisions shall remain in full force, and, to the extent permitted, the invalid provision shall be reformed to accomplish its essential purpose.

9.4 Integration
This DNRO constitutes the entire agreement with respect to the subject matter and supersedes all prior oral or written statements regarding resuscitation wishes.

9.5 Electronic Copies
Photocopies, facsimiles, and electronically transmitted copies bearing original signatures shall be deemed originals for all purposes.

10. EXECUTION BLOCK

[// GUIDANCE: Utah law permits EITHER (i) two adult witnesses OR (ii) a notary acknowledgment. EMS recognition additionally requires a licensed Provider signature.]

10.1 Principal

10.2 Authorized Health-Care Provider

I certify that I have discussed the medical indications and consequences of this DNRO with the Principal (or the Principal’s legally authorized surrogate) and find it medically appropriate.

10.3 Witnesses (complete A or B)

A. Two (2) Adult Witnesses

Each witness declares under penalty of perjury that the Principal signed or acknowledged this DNRO in their presence, appeared to be of sound mind, and was not acting under duress, fraud, or undue influence.

OR

B. Notary Acknowledgment (alternative to witnesses)

State of Utah )
County of ______ ) ss.

On this _ day of _, 20__, before me, the undersigned Notary Public, personally appeared ________, known or proved to me to be the person whose name is subscribed to the foregoing DNRO, and acknowledged that he/she executed the same voluntarily for the purposes therein contained.

Notary Public: ______
My Commission Expires: ____

10.4 EMS Verification Section (Optional but Recommended)

This section may be completed by EMS personnel at first contact.

• DNRO Presented? □ Original □ Copy □ Bracelet/Card
• DNRO Appears Valid/Unrevoked? □ Yes □ No
• EMS Action Taken: _______
• EMS Provider Signature & Employee/License #: ___
• Date & Time: _____

[// GUIDANCE: Insert firm letterhead or footer as desired. Prior to client delivery, counsel should:
1. Confirm any Department of Health form-number/color requirements;
2. Attach complementary Utah Advance Health Care Directive if broader treatment instructions are desired;
3. Educate client on practical steps—e.g., refrigerator placement for EMS visibility.]