Medical Directive - DNR

VERMONT DO-NOT-RESUSCITATE (DNR) / CLINICIAN ORDER

TABLE OF CONTENTS

1. Document Header...........................................2
2. Definitions................................................3
3. Operative Provisions.......................................4
4. Representations & Warranties...............................6
5. Covenants & Restrictions...................................7
6. Default & Remedies.........................................8
7. Risk Allocation............................................9
8. Dispute Resolution........................................10
9. General Provisions........................................11
10. Execution Block..........................................12
11. Portable “Wallet Card” (Optional)........................15

1. DOCUMENT HEADER

1.1 Title and Parties

This Vermont Do-Not-Resuscitate / Clinician Order (the “Directive”) is executed by [PATIENT FULL LEGAL NAME] (“Patient”) and countersigned by [CLINICIAN NAME & CREDENTIALS] (“Clinician”), together with any appointed health-care agent or surrogate listed herein (the “Agent,” if any).

1.2 Recitals

A. Patient, being of sound mind and acting voluntarily, desires to direct that no cardiopulmonary resuscitation measures be undertaken in the event of cardiac or respiratory arrest.
B. Vermont law (18 V.S.A. § 9708) authorizes a DNR/COLST order that, when properly executed, must be honored by all licensed health-care providers and Emergency Medical Service (“EMS”) personnel operating within the State of Vermont.
C. Clinician, having evaluated Patient, issues this Directive as a medical order in good faith and in accordance with prevailing standards of care.

1.3 Effective Date & Duration

This Directive becomes effective on [EFFECTIVE DATE] and remains in force until revoked pursuant to Section 3.5.

1.4 Governing Law

This Directive shall be governed by and construed in accordance with the laws of the State of Vermont.

2. DEFINITIONS

“Advance Directive” – An instruction recognized under 18 V.S.A. § 9700 et seq. regarding health-care decisions if the principal lacks capacity.

“Agent” – The individual legally appointed under an Advance Directive or durable power of attorney for health care to make decisions on Patient’s behalf.

“Cardiopulmonary Resuscitation” or “CPR” – Any medical intervention intended to restore spontaneous circulation or breathing, including chest compressions, defibrillation, or advanced airway management.

“Clinician” – A physician, advanced practice registered nurse, or physician assistant licensed in Vermont and authorized to sign DNR/COLST orders.

“DNR Order” or “Directive” – This written medical order to withhold CPR, recognized under 18 V.S.A. § 9708.

“EMS” – Emergency Medical Services personnel licensed under 24 V.S.A. Chapter 71.

“Good Faith” – Honesty in fact and the reasonable belief that actions are in accordance with applicable law and prevailing medical standards.

“Qualified Witness” – An adult who: (i) is not Patient’s Agent, (ii) does not provide direct health care to Patient, and (iii) is not entitled to any portion of Patient’s estate.

3. OPERATIVE PROVISIONS

3.1 Directive and Medical Order

3.1.1 Patient hereby directs, and Clinician hereby orders, that no CPR be attempted if Patient experiences cardiopulmonary arrest.
3.1.2 All other medical care shall be provided consistent with Patient’s stated preferences in Section 3.3 and applicable standards of comfort-focused treatment.

3.2 Authorization to EMS and Health-Care Providers

All Vermont-licensed EMS personnel and health-care providers shall honor this Directive in accordance with 18 V.S.A. § 9708 and the current Vermont Statewide EMS Protocols.

3.3 Scope of Treatment

☐ Comfort-Focused Treatment Only
☐ Limited Additional Interventions (e.g., IV fluids, non-invasive airway)
☐ Other Instructions: [INSERT ADDITIONAL PATIENT INSTRUCTIONS]

3.4 Documentation & Accessibility

3.4.1 The original Directive shall accompany Patient at all times while in a health-care facility and shall be prominently placed in Patient’s medical record.
3.4.2 A portable copy (wallet card) may be created in the form provided in Section 11.

3.5 Revocation and Modification

3.5.1 Patient (or Agent, if Patient lacks capacity) may revoke this Directive at any time by oral or written statement or by destroying the document.
3.5.2 Clinician shall record any revocation in Patient’s chart and, if feasible, retrieve and void all known copies.

3.6 Successor Orders

Issuance of a new, duly executed DNR/COLST order automatically supersedes this Directive.

4. REPRESENTATIONS & WARRANTIES

4.1 Patient Representations

A. Capacity: Patient affirms possessing decision-making capacity at the time of signing.
B. Voluntariness: Execution is free of undue influence or duress.
C. Disclosure: Patient has informed (or will inform) Family and Agent of this choice.

4.2 Clinician Representations

A. Evaluation: Clinician has personally examined Patient and discussed prognosis and alternatives.
B. Compliance: Clinician has complied with all requirements of 18 V.S.A. § 9708 and Department of Health rules.
C. Good Faith: Clinician issues this Directive in good faith and in the Patient’s best interests.

4.3 Survival

Representations herein survive revocation only to the extent necessary to determine validity at the time care was rendered.

5. COVENANTS & RESTRICTIONS

5.1 Patient/Agent covenants to provide copies of this Directive to subsequent treating facilities.
5.2 Clinician covenants to review the Directive periodically, or upon material change in Patient’s condition, and to reaffirm or revise as clinically appropriate.
5.3 No party may alter the Directive except through a duly executed modification pursuant to Section 3.5.

6. DEFAULT & REMEDIES

6.1 Failure to Honor. Any provider who, absent statutory immunity, willfully disregards this Directive may be subject to professional discipline under 26 V.S.A. and civil liability.
6.2 Complaint Procedure. Patient or Agent may file a complaint with the Vermont Board of Medical Practice or Board of Nursing, as applicable.
6.3 Cure. A provider acting in good faith reliance on an apparently valid Directive shall be deemed to have satisfied any cure requirement.

7. RISK ALLOCATION

7.1 Provider Protection (Indemnification)

Patient (and Patient’s estate) agrees to indemnify and hold harmless Clinician and any treating provider or EMS personnel from liability for acts or omissions taken in good-faith reliance on this Directive, except in cases of gross negligence or willful misconduct.

7.2 Limitation of Liability

No provider or EMS personnel acting in compliance with this Directive and in good faith shall be liable for civil damages or subject to criminal prosecution, consistent with 18 V.S.A. § 9709.

7.3 Insurance

Nothing herein expands or contracts any professional liability insurance coverage.

8. DISPUTE RESOLUTION

8.1 Governing Law: Vermont law governs any dispute arising under or relating to this Directive.
8.2 Injunctive Relief: Patient or Agent may seek injunctive relief to enforce the Directive’s terms.

9. GENERAL PROVISIONS

9.1 Amendments must be in writing and executed with the same formalities as this Directive.
9.2 Severability. Invalidity of any provision shall not affect remaining provisions.
9.3 Integration. This Directive constitutes the complete agreement regarding the subject matter and supersedes all prior directives to the extent of any inconsistency.
9.4 Counterparts; Electronic Signatures. This Directive may be executed in multiple counterparts, including electronically, each of which is deemed an original.

10. EXECUTION BLOCK

10.1 PATIENT SIGNATURE

I, [PATIENT FULL LEGAL NAME], voluntarily execute this Directive and affirm that I understand its meaning and effect.

Signature: ___________________________________ Date: _______________
Address: [PATIENT ADDRESS]
Date of Birth: [MM/DD/YYYY]   Last 4 SSN: [####]

10.2 OPTIONAL AGENT / SURROGATE

I, [AGENT NAME], acknowledge my appointment and intention to honor Patient’s wishes.

Signature: ___________________________________ Date: _______________

10.3 CLINICIAN ATTESTATION & ORDER

I have reviewed Patient’s medical history, discussed goals of care, and hereby issue this DNR/COLST order.

Clinician Name & Credential: [CLINICIAN NAME, M.D./D.O./APRN/PA]
License No.: [LICENSE #]  Phone: [###-###-####]
Signature: ___________________________________ Date: _______________

10.4 WITNESS CERTIFICATION

We declare under penalty of perjury that Patient appeared to be of sound mind, signed or acknowledged this Directive in our presence, and that we are Qualified Witnesses.

Witness 1: ___________________________________ Date: _______________
Printed Name: [WITNESS 1 NAME] Address: [ADDRESS]

Witness 2: ___________________________________ Date: _______________
Printed Name: [WITNESS 2 NAME] Address: [ADDRESS]

10.5 OPTIONAL NOTARIZATION

State of Vermont, County of [COUNTY]
Subscribed and sworn before me this ___ day of __________, 20__.

Notary Public: ______________________________ My Comm. Exp.: ________

11. PORTABLE “WALLET CARD” (Detach or Copy)

Vermont DNR/COLST – Patient [LAST NAME], DOB [DOB]
NO CPR – EMS MUST HONOR
Clinician: [NAME & PHONE] Effective: [DATE]
In emergency, present this card and full Directive to responders.