WASHINGTON STATE

MEDICAL DIRECTIVE – DO NOT RESUSCITATE (DNR) ORDER

(Draft Template – Court-Ready / Attorney Use Only)

[// GUIDANCE:
1. This template is structured to satisfy (a) Washington State statutory and regulatory requirements for a valid Do-Not-Resuscitate order, including EMS recognition under RCW 43.70.480, and (b) the client’s risk-management objectives (provider protection; good-faith liability cap).
2. The document mirrors a full contract architecture for consistency with firm drafting standards. Sections III–VIII are streamlined for a medical order but preserved to facilitate integration with broader health-care planning packets.
3. Replace all bracketed placeholders BEFORE execution. Ensure the issuing provider is licensed in Washington (MD/DO/ARNP/PA-C) and uses bright “pulsar” pink (Pantone #238C) card stock for EMS field recognition.
]

TABLE OF CONTENTS

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

1. DOCUMENT HEADER

1.1 Title

WASHINGTON STATE MEDICAL DIRECTIVE – DO NOT RESUSCITATE (DNR) ORDER

1.2 Parties

a. “Patient” – [LEGAL NAME], DOB [MM/DD/YYYY], last four SSN [####]
b. “Authorized Provider” – [NAME, CREDENTIALS, LICENSE #]
c. “Health-Care Agent” (if any) – [AGENT NAME] under Durable Power of Attorney for Health Care dated [DATE]

1.3 Recitals

WHEREAS, Patient, having decision-making capacity or acting through an authorized Health-Care Agent, desires to direct that no resuscitative efforts be undertaken in the event of cardiopulmonary arrest; and
WHEREAS, Authorized Provider is licensed to issue medical orders in the State of Washington and has determined, in consultation with Patient, that this DNR Order is clinically appropriate and consistent with Patient’s wishes and best interests;

NOW, THEREFORE, the Parties agree as follows:

1.4 Effective Date & Jurisdiction

This Medical Directive becomes effective on the date of the last signature below and shall be governed by the laws of the State of Washington, including but not limited to Wash. Rev. Code § 43.70.480 (2023).

2. DEFINITIONS

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

“Agent” – An individual authorized under a valid Washington Durable Power of Attorney for Health Care to make health-care decisions on behalf of the Patient.

“Authorized Provider” – A physician (MD/DO), advanced registered nurse practitioner (ARNP), or physician assistant-certified (PA-C) licensed in the State of Washington and acting within the scope of practice.

“CPR” – Cardiopulmonary resuscitation, including chest compressions, defibrillation, advanced airway management, artificial ventilation, and administration of resuscitative medications.

“DNR Order” or “Order” – This written, signed medical order directing that no resuscitative efforts be attempted in the event of cardiopulmonary arrest.

“EMS” – Prehospital emergency medical services personnel certified or licensed in Washington State.

“Good Faith” – Honest intent to act without malice, negligence, or intent to defraud, consistent with generally accepted health-care standards.

“Revocation” – A Patient’s oral or written expression, physical destruction of the form, or execution of a superseding directive that nullifies this DNR Order.

3. OPERATIVE PROVISIONS

3.1 Core Directive

The Patient does not consent to CPR or any resuscitative measures if the Patient experiences cardiac or respiratory arrest. No person, including EMS, hospital staff, or other health-care providers, shall initiate CPR on the Patient once arrest is confirmed.

3.2 Scope of Application

a. Prehospital Settings – This Order is valid in the community, during transport, and in any non-hospital environment within Washington State.
b. In-Facility Settings – This Order shall be honored in hospitals, nursing homes, assisted living facilities, and any facility licensed under Washington law unless overridden by subsequent, facility-specific physician orders consistent with this Directive.

3.3 Treatment NOT Prohibited

This Order does not preclude:
i. Comfort-focused palliative care, pain control, or other non-resuscitative treatments;
ii. Provision of oxygen, suctioning of airway secretions, or control of bleeding when clinically indicated for comfort;
iii. Artificial nutrition/hydration or other life-prolonging measures unless separately limited by the Patient’s Advance Directive or Physician Orders for Life-Sustaining Treatment (POLST).

3.4 Conditions Precedent

The Authorized Provider’s signature under Section 10 is a condition precedent to enforceability.

4. REPRESENTATIONS & WARRANTIES

4.1 Patient (or Agent) represents that:
a. The Patient is at least eighteen (18) years of age or an emancipated minor;
b. The Patient possesses decision-making capacity OR the undersigned Agent is authorized to act;
c. Execution of this Directive is voluntary and free from duress.

4.2 Authorized Provider represents that:
a. Provider is duly licensed and in good standing in Washington;
b. Provider has discussed the medical implications of a DNR order with the Patient/Agent;
c. Provider has executed this Directive in Good Faith and consistent with applicable professional standards.

4.3 Survival
The warranties set forth in this Section survive Revocation only to the extent necessary to enforce any indemnification or liability limitations accruing prior to Revocation.

5. COVENANTS & RESTRICTIONS

5.1 Patient Covenants
a. Patient shall keep the original form readily available and, when outside a facility, carry a reduced-size copy or bracelet/necklace that references this DNR Order.
b. Patient shall promptly notify Provider of any desire to revoke or amend the Order.

5.2 Provider Covenants
a. Provider shall enter an appropriate notation in Patient’s medical record and, when feasible, communicate the existence of this Order to other treating providers.
b. Provider shall review the continued appropriateness of this Order upon any substantial change in Patient’s health status.

5.3 Revocation Procedure
This Order may be revoked at any time by:
i. Patient’s oral statement to a provider or EMS personnel;
ii. Physical destruction or defacement of the form; or
iii. Execution of a subsequent, conflicting directive.

6. DEFAULT & REMEDIES

6.1 Events of Default
a. Provider Default – Knowing failure by a provider to honor this Directive absent a statutory or ethical exception.
b. Patient Default – Misrepresentation of identity or falsification of medical decision-making authority.

6.2 Notice & Cure
a. Provider Default – Patient/Agent shall provide written notice to the provider and allow a reasonable opportunity to cure when cure is practicable (e.g., correction of medical record).
b. Patient Default – Provider may consider the Order void ab initio upon discovery of fraud; no cure period required.

6.3 Remedies
a. Injunctive Relief – Either party may seek declaratory or injunctive relief to enforce or clarify this Directive.
b. Attorneys’ Fees – Prevailing party in any action to enforce this Directive is entitled to reasonable attorneys’ fees and costs.

7. RISK ALLOCATION

7.1 Indemnification – Provider Protection

Patient (and Patient’s estate) shall indemnify, defend, and hold harmless Authorized Provider, EMS personnel, and any other health-care provider who, in Good Faith, withholds or withdraws CPR in reliance on this Order, against any and all claims, liabilities, damages, or expenses arising from such reliance, except to the extent caused by gross negligence or willful misconduct.

7.2 Limitation of Liability – Good-Faith Standard

No provider, EMS agency, or health-care facility acting in Good Faith reliance on this DNR Order shall be liable to the Patient, the Patient’s estate, or any third party for civil damages or be subject to criminal prosecution or professional discipline for honoring or failing to honor this Order, consistent with RCW 43.70.480 and applicable professional-practice statutes.

7.3 Insurance

[OPTIONAL – include if facility or provider requires proof of professional liability coverage.]

7.4 Force Majeure

N/A – Not applicable to medical orders; omitted intentionally.

8. DISPUTE RESOLUTION

8.1 Governing Law
This Directive is governed by the laws of the State of Washington, without regard to conflict-of-laws principles.

8.2 Forum Selection
Any proceeding arising under or relating to this Directive shall be brought exclusively in the courts of competent jurisdiction located in [COUNTY], Washington.

8.3 Arbitration; Jury Waiver
Not applicable.

8.4 Injunctive Relief
Nothing herein limits the right of any party or interested person to seek injunctive or declaratory relief to enforce the terms of this Directive in any court of competent jurisdiction.

9. GENERAL PROVISIONS

9.1 Amendment & Waiver
This Directive may be amended only by a writing signed by the Patient (or Agent) and Authorized Provider. No waiver of any term shall be effective unless in writing.

9.2 Assignment
Rights and obligations hereunder are personal to the Patient and may not be assigned.

9.3 Successors & Assigns
This Directive binds and inures to the benefit of the Patient’s heirs, executors, administrators, and legal representatives, and to all providers acting in Good Faith reliance hereon.

9.4 Severability
If any provision of this Directive is held invalid or unenforceable, the remaining provisions shall remain in full force and effect, and the invalid portion shall be construed, if possible, to give effect to the original intent.

9.5 Integration
This Directive constitutes the entire agreement and medical order concerning CPR for the Patient, superseding all prior or contemporaneous instructions to the contrary.

9.6 Counterparts; Electronic Signatures
This Directive may be executed in counterparts, each of which is deemed an original. Electronic or facsimile signatures shall be treated as originals for all purposes to the extent permitted by Washington law.

10. EXECUTION BLOCK

[// GUIDANCE: Two adult witnesses are REQUIRED if the Patient lacks capacity and an Agent is signing. Notarization is recommended but not mandated under RCW 43.70.480.]

10.1 Patient (or Agent) Signature

I affirm that I understand the implications of this DNR Order and that it reflects my (the Patient’s) voluntary and informed decision.

Signature: _____ Date: _
Print Name: ____ Relationship: ☐ Patient ☐ Health-Care Agent

10.2 Witnesses

Witness 1 Signature: ___ Date: _
Print Name: ____ Address / Phone: ____

Witness 2 Signature: ___ Date: _
Print Name: ____ Address / Phone: ____

[// GUIDANCE: Witnesses must be at least 18, not related to the Patient, and not entitled to any portion of the Patient’s estate.]

10.3 Authorized Provider

I hereby issue this medical order in accordance with Washington law and my professional judgment.

Signature: ______ Date: __
Printed Name & Credentials: ______
WA License No.: _____ Phone: _
Facility / Practice Address: _____

11. OPTIONAL WALLET CARD

Cut along dotted line and carry in wallet.

WASHINGTON DNR ORDER – WALLET CARD
Patient: [NAME] DOB: [MM/DD/YYYY]
“No CPR / No Defibrillation – See pink DNR form.”
Provider Signature: ___ Phone: _
Date: _______

[// GUIDANCE:
• File original in Patient’s medical record; provide copies to EMS agency, nursing facility, and Health-Care Agent.
• Reassess at least annually or upon change in Patient’s health status.
• If converting to POLST, mark this DNR “VOID” and destroy all copies.
]