DO-NOT-RESUSCITATE DIRECTIVE
(Wisconsin – Pursuant to Wis. Stat. §§ 154.17 – 154.29 (2023))
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
1.1 Title
Do-Not-Resuscitate Directive (the “Directive”).
1.2 Parties
a. “Patient”: [FULL LEGAL NAME], date of birth [MM/DD/YYYY], residing at [ADDRESS].
b. “Attending Physician”: [PHYSICIAN NAME], M.D./D.O., Wisconsin license no. [NUMBER], practice address [ADDRESS].
c. “Health-Care Provider(s)”: any individual or facility providing medical care to the Patient, including Emergency Medical Services (“EMS”) personnel.
1.3 Recitals
a. The Patient desires, in the event of cardiac or respiratory arrest, that no cardiopulmonary resuscitation (“CPR”) or other resuscitative measures be initiated.
b. The Attending Physician, after appropriate consultation and in accordance with Wis. Stat. ch. 154, Subch. III, concurs in writing with the Patient’s decision.
c. Consideration is acknowledged by the mutual promises contained herein and by the statutory protections afforded to providers acting in good faith reliance on this Directive.
1.4 Effective Date & Governing Law
This Directive is effective upon the later of (i) the date signed by the Patient, and (ii) the date countersigned by the Attending Physician (the “Effective Date”), and shall be governed by the laws of the State of Wisconsin.
2. DEFINITIONS
For ease of reference, capitalized terms have the meanings assigned below:
“Cardiac Arrest” – Cessation of cardiac mechanical activity, confirmed by the absence of a detectable pulse, unresponsiveness, and apnea.
“DNR Bracelet” – A metal bracelet bearing the approved inscription under Wis. Stat. § 154.19 (3), issued by an authorized vendor and uniquely identifying the Patient’s valid DNR order.
“Do-Not-Resuscitate” or “DNR” – A medical order directing that no CPR or advanced cardiac life support protocols be initiated in the event of Cardiac Arrest or Respiratory Arrest.
“Good Faith” – Honesty in fact in the conduct or transaction concerned and reasonable reliance upon the validity of this Directive.
“Qualified Witness” – An individual at least 18 years old who is not (i) related to the Patient by blood, marriage, or adoption, (ii) entitled to any portion of the Patient’s estate, or (iii) directly responsible for the Patient’s medical care.
“Respiratory Arrest” – Cessation of spontaneous respiratory effort leading to absence of breathing.
3. OPERATIVE PROVISIONS
3.1 DNR Order
The Patient hereby directs and the Attending Physician hereby orders that, upon occurrence of Cardiac Arrest or Respiratory Arrest, no CPR, defibrillation, advanced airway management, cardiac drugs, or artificial ventilation shall be administered.
3.2 Scope of Directive
a. This Directive applies in all settings, including hospitals, long-term-care facilities, ambulances, and the Patient’s residence.
b. Comfort care, pain management, and other non-resuscitative medical treatments remain fully authorized.
3.3 EMS Recognition
The Patient (or legal representative) shall wear an approved Wisconsin DNR Bracelet or otherwise present this Directive to EMS personnel. EMS providers who, in Good Faith, rely on a visible DNR Bracelet or this Directive are immune from civil or criminal liability pursuant to Wis. Stat. § 154.27.
3.4 Conditions Precedent
This Directive is conditioned upon (i) the Patient’s voluntary execution, and (ii) the Attending Physician’s written confirmation that the Patient (or legal representative) gave informed consent.
3.5 Revocation
a. The Patient may revoke this Directive at any time by oral expression of intent to resuscitate, removal of the DNR Bracelet, or destruction of this document.
b. Revocation shall become effective immediately upon such expression or act.
3.6 Duration
Absent revocation, this Directive remains in force indefinitely, including during transfers between health-care facilities.
4. REPRESENTATIONS & WARRANTIES
4.1 Patient Representations
a. Capacity: The Patient declares being of sound mind and at least 18 years of age.
b. Voluntariness: Execution is voluntary and free from duress or undue influence.
c. Disclosure: The Patient has discussed the implications of a DNR order with the Attending Physician.
4.2 Physician Representations
a. Compliance: The Attending Physician affirms compliance with Wis. Stat. §§ 154.17–154.29 and any applicable Wisconsin Administrative Code provisions.
b. Medical Judgment: The Physician has determined that a DNR order is appropriate given the Patient’s condition and wishes.
4.3 Survival
The representations and warranties in this Section survive the Patient’s incapacity and remain enforceable by Health-Care Providers relying in Good Faith on the Directive.
5. COVENANTS & RESTRICTIONS
5.1 Patient Covenants
a. Wear DNR Bracelet: The Patient shall wear or otherwise maintain the DNR Bracelet when outside a medical facility.
b. Notice: The Patient shall provide copies of this Directive to primary Health-Care Providers and facilities.
5.2 Provider Covenants
Health-Care Providers shall insert this Directive into the Patient’s medical record promptly upon receipt.
5.3 Restrictions
No party may alter the medical scope of this Directive except by executing a new directive in compliance with Wisconsin law.
6. DEFAULT & REMEDIES
6.1 Events of Default
a. Failure by a Health-Care Provider to honor this Directive absent statutory exception.
b. Failure to document revocation as required by Section 3.5.
6.2 Notice & Cure
Upon awareness of an alleged default, the Patient’s legal representative shall provide written notice to the Health-Care Provider, who shall have an immediate duty to cease further resuscitative measures unless otherwise authorized by law.
6.3 Remedies
a. Injunctive Relief: The Patient or representative may seek equitable relief to enforce the Directive.
b. Costs & Fees: A prevailing party in enforcement proceedings is entitled to reasonable attorney fees and costs.
7. RISK ALLOCATION
7.1 Indemnification of Providers
The Patient (and estate) agrees to indemnify and hold harmless Health-Care Providers from liability arising out of Good-Faith compliance with, or reliance on, this Directive, except in cases of gross negligence or willful misconduct.
7.2 Limitation of Liability
Health-Care Providers acting in Good Faith shall not be liable for civil damages or subject to criminal prosecution for withholding or withdrawing resuscitative measures pursuant to this Directive.
7.3 Insurance
[// GUIDANCE: Insert any professional liability insurance requirements only if expressly mandated by institutional policy.]
7.4 Force Majeure
Performance obligations under this Directive are excused to the extent rendered impossible by natural disaster, war, or other events beyond the reasonable control of the affected party; provided, however, that emergency medical providers must still comply with statutory duties.
8. DISPUTE RESOLUTION
8.1 Governing Law
This Directive shall be interpreted exclusively under the laws of the State of Wisconsin without regard to conflict-of-laws principles.
8.2 Forum Selection
State and federal courts sitting in [COUNTY], Wisconsin, shall have exclusive jurisdiction over any action arising under or relating to this Directive.
8.3 Injunctive Relief
Nothing herein limits the right of any party to seek temporary, preliminary, or permanent injunctive relief to enforce the terms of this Directive.
8.4 Jury Waiver & Arbitration
Not applicable.
9. GENERAL PROVISIONS
9.1 Amendment & Waiver
This Directive may be amended only by a new written directive executed in the manner required by Wisconsin law. No waiver of any provision shall be effective unless in writing and signed by the Patient (or legal representative).
9.2 Assignment
This Directive is personal to the Patient and shall not be assigned.
9.3 Successors & Assigns
The obligations of Health-Care Providers under this Directive bind their respective successors, assigns, and personnel.
9.4 Severability
If any provision is held invalid or unenforceable, the remaining provisions shall remain in full force to the maximum extent permitted.
9.5 Integration
This Directive constitutes the complete and exclusive statement of the Patient’s DNR wishes and supersedes all prior statements to the contrary.
9.6 Counterparts; Electronic Signatures
This Directive may be executed in counterparts and by electronic signature, each of which is deemed an original.
10. EXECUTION BLOCK
10.1 Patient Signature
I, the undersigned Patient, have read and understand this Directive and voluntarily execute it on the date shown.
| Signature | Date |
|---|---|
| _________ | _____ |
10.2 Physician Confirmation
I, the undersigned Attending Physician, affirm that I have discussed the implications of a DNR order with the Patient or the Patient’s legal representative, and I hereby issue the medical order set forth in Section 3.1.
| Physician Signature | Date |
|---|---|
| _________ | _____ |
10.3 Witness Acknowledgments
As Qualified Witnesses, we declare that the Patient signed or acknowledged this Directive in our presence, appears to be of sound mind, and is acting voluntarily and free from duress.
| Witness #1 Signature | Printed Name | Date |
|---|---|---|
| ___ | ________ | _____ |
| Witness #2 Signature | Printed Name | Date |
|---|---|---|
| ___ | ________ | _____ |
[// GUIDANCE: Wisconsin does not statutorily require witnesses for a DNR order signed by the physician; however, obtaining two disinterested witnesses enhances evidentiary reliability, particularly outside clinical settings.]
10.4 Notary Public (Optional)
State of Wisconsin )
County of [COUNTY] )
Subscribed and sworn before me on [DATE] by [NAME OF PATIENT].
Notary Public ____
My Commission Expires: _______
10.5 DNR Bracelet Information (if issued)
Vendor: ____
Bracelet Serial No.: ___
Date Affixed: _______
[// GUIDANCE:
1. File the executed Directive in the Patient’s medical record and provide copies to key family members, EMS agencies, and long-term-care facilities.
2. Advise the Patient to carry a laminated wallet card referencing this Directive and DNR Bracelet serial number.
3. Review the Directive periodically—especially upon changes in health status—to confirm continued intent.]