WYOMING DO NOT RESUSCITATE (DNR) MEDICAL DIRECTIVE
[// GUIDANCE: This form is designed to satisfy Wyoming‐specific statutory and regulatory requirements for a Do Not Resuscitate (“DNR”) directive, including EMS recognition, witness formalities, and provider immunity provisions. Customize all bracketed items and obtain independent legal/medical review prior to use.]
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 and Parties
THIS WYOMING DO NOT RESUSCITATE MEDICAL DIRECTIVE (this “Directive”) is executed by [Full Legal Name of Patient] (“Declarant” or “Patient”) in consultation with [Full Name of Attending Physician/APRN] (“Attending Practitioner”) and shall be relied upon by all Authorized Health-Care Providers (as defined below).
1.2 Recitals
A. Declarant desires to exercise the right, recognized under Wyoming law, to refuse cardiopulmonary resuscitation (“CPR”) and other specified resuscitative measures in the event of [Declarant’s medical condition—e.g., terminal illness, advanced age, etc.].
B. Attending Practitioner concurs that issuance of this Directive is medically appropriate.
C. The parties intend that Emergency Medical Services (“EMS”) personnel and all Health-Care Providers honor this Directive in good faith.
1.3 Effective Date; Governing Law
This Directive is effective on [Effective Date] and shall be governed by the health-care laws of the State of Wyoming (“Governing Law”).
2. DEFINITIONS
For ease of reference, capitalized terms have the meanings set forth below:
“Authorized Health-Care Provider” means any individual licensed, certified, or otherwise authorized in Wyoming to administer health care and who, in good faith, relies on this Directive.
“Cardiopulmonary Resuscitation” or “CPR” means chest compressions, artificial ventilation, defibrillation, endotracheal intubation, administration of cardiac drugs, or any other procedure that may restore cardiac or respiratory function.
“Comfort Care” means any measure intended to alleviate pain or provide emotional support, including oxygen, analgesics, anti-anxiety medication, suctioning, and positioning.
“Directive” means this Wyoming Do Not Resuscitate Medical Directive, as it may be amended or revoked in accordance with its terms.
“EMS Recognition” means recognition and compliance by Wyoming-licensed emergency responders pursuant to applicable Wyoming Department of Health protocols.
“Good-Faith Standard” means honest reliance on this Directive without actual knowledge of its revocation, suspension, or invalidity.
“Patient Representative” means the individual authorized by the Declarant under a valid health-care power of attorney, or, if none, the person having priority to make health-care decisions under Wyoming’s default surrogate hierarchy.
3. OPERATIVE PROVISIONS
3.1 Instruction to Withhold CPR
Declarant hereby directs all Authorized Health-Care Providers and EMS personnel to withhold CPR and all other resuscitative measures in the event the Declarant experiences cardiopulmonary arrest.
3.2 Scope of Withheld Interventions
The following interventions are specifically REFUSED unless separately authorized post-execution:
a. Defibrillation or cardioversion;
b. Advanced airway management, including endotracheal intubation;
c. Administration of resuscitative medications intended to restart or support cardiac function.
[// GUIDANCE: If Declarant desires to refuse additional interventions (e.g., assisted ventilation absent arrest), list them here.]
3.3 Comfort Care Affirmation
Nothing in this Directive shall preclude or delay the provision of Comfort Care, palliative measures, or other treatments intended solely to alleviate pain or suffering.
3.4 EMS Recognition Requirements
a. Form Presentation. A completed original, legible copy, or a Wyoming-approved DNR bracelet/necklace shall constitute valid proof to EMS.
b. Obligation to Honor. EMS personnel acting under Wyoming protocols shall honor this Directive in accordance with the Good-Faith Standard.
c. Documentation. Attending Practitioner shall enter an order referencing this Directive in the Patient’s medical record and, when feasible, affix a copy to the chart.
3.5 Revocation; Suspension
a. By Declarant. Declarant may revoke this Directive at any time by:
i. Oral or written statement to any Health-Care Provider;
ii. Physical destruction of the Directive; or
iii. Removal of an identifying DNR bracelet/necklace.
b. By Attending Practitioner. Attending Practitioner may suspend the Directive if clinical circumstances materially change and written notice is provided to Declarant or Patient Representative.
c. Effect of Revocation/Suspension. Upon actual notice, Health-Care Providers shall disregard the Directive and resume full resuscitative efforts unless or until a new Directive is issued.
3.6 Consideration
The mutual promises herein, the provision of medical services, and the reliance by Health-Care Providers on the Good-Faith Standard constitute sufficient consideration.
3.7 Conditions Precedent
This Directive shall be operative only when Declarant is found pulseless, apneic, or otherwise in cardiopulmonary arrest.
4. REPRESENTATIONS & WARRANTIES
4.1 Declarant represents, warrants, and covenants that:
a. Declarant is at least 18 years of age and of sound mind;
b. Execution of this Directive is voluntary and free from coercion;
c. Declarant has been informed of the medical consequences of issuing a DNR order;
d. Declarant has had the opportunity to consult legal and medical advisors.
4.2 Attending Practitioner represents and warrants that:
a. Practitioner is duly licensed in Wyoming;
b. Practitioner has explained to Declarant the nature, scope, and implications of this Directive;
c. Practitioner believes, in good faith, that issuance of this Directive is medically appropriate.
[// GUIDANCE: Additional warranties (e.g., absence of conflicting advance directives) may be added based on client circumstances.]
5. COVENANTS & RESTRICTIONS
5.1 Declarant covenants to:
a. Inform future Health-Care Providers of the existence of this Directive;
b. Wear or carry Wyoming-approved DNR identification if desired;
c. Supply copies of this Directive to significant family members and Patient Representative.
5.2 Attending Practitioner covenants to:
a. Ensure this Directive (or a notation thereof) is placed prominently within Declarant’s medical record;
b. Review the Directive’s continued appropriateness at each significant change in Declarant’s medical status.
6. DEFAULT & REMEDIES
6.1 Events of Default
It shall constitute an Event of Default if any Health-Care Provider, with actual knowledge of this Directive and absent a legal exception, administers CPR contrary to Section 3.1.
6.2 Notice and Cure
Prompt written notice of an Event of Default shall be given to the Health-Care Provider and, if applicable, the governing licensing board. Health-Care Provider shall have no cure period for CPR rendered in violation of a valid Directive.
6.3 Remedies
a. Equitable Relief: Declarant (or estate) may seek injunctive or declaratory relief to enforce compliance with this Directive.
b. Administrative Complaint: Declarant (or estate) may file a complaint with the Wyoming Department of Health or pertinent licensing authority.
c. Statutory Remedies: Any statutory remedy available under Wyoming law is expressly preserved.
[// GUIDANCE: Monetary damages are uncommon in DNR disputes; nevertheless, inclusion supports defensive drafting.]
7. RISK ALLOCATION
7.1 Provider Protection & Indemnification
Declarant agrees to indemnify and hold harmless any Authorized Health-Care Provider who, in good faith, relies upon, or attempts to comply with, this Directive against any civil, criminal, or administrative liability, except for acts constituting gross negligence or willful misconduct.
7.2 Limitation of Liability (Good-Faith Standard)
To the fullest extent permitted by Wyoming law, liability of any Health-Care Provider for honoring this Directive in good faith shall be limited to acts of gross negligence or willful misconduct.
7.3 Insurance
No additional insurance requirements are imposed by this Directive.
7.4 Force Majeure
Health-Care Providers shall not be deemed in default for failure or delay in complying with this Directive when such failure is caused by circumstances beyond reasonable control, including natural disaster, mass casualty incident, or other declarations of emergency that render compliance impossible.
8. DISPUTE RESOLUTION
8.1 Governing Law
This Directive shall be governed by and construed in accordance with the health-care laws of the State of Wyoming.
8.2 Forum Selection, Arbitration, Jury Waiver
Not applicable.
8.3 Injunctive Relief
Nothing herein shall limit the right of Declarant, Patient Representative, or estate to seek injunctive relief to enforce or prevent violation of this Directive.
9. GENERAL PROVISIONS
9.1 Amendment & Waiver
This Directive may be amended only by a subsequent writing executed with the same formalities as this Directive. No waiver of any provision shall be effective unless in writing and signed by Declarant.
9.2 Assignment
Rights and duties under this Directive are personal to Declarant and may not be assigned.
9.3 Successors & Assigns
This Directive shall bind the estate, heirs, personal representatives, and permitted assigns of Declarant and shall inure to the benefit of Authorized Health-Care Providers acting under the Good-Faith Standard.
9.4 Severability
If any provision herein is held invalid or unenforceable, the remainder of this Directive shall remain in full force and effect, and the invalid provision shall be reformed to the minimum extent necessary to comply with Governing Law.
9.5 Integration
This Directive constitutes the entire agreement concerning resuscitative measures and supersedes all prior inconsistent statements or writings by Declarant, except any living will or health-care power of attorney that is not inconsistent with this Directive.
9.6 Counterparts; Electronic Signature
This Directive may be executed in multiple counterparts, each of which shall be deemed an original. Signatures transmitted via electronic or facsimile means shall be deemed originals for all purposes, to the extent permitted by Wyoming law.
10. EXECUTION BLOCK
[// GUIDANCE: Wyoming permits either two adult witnesses OR notarization. Witnesses may NOT be the attending practitioner, a relative by blood or marriage, or a person entitled to any portion of the Declarant’s estate. Complete ONE of the following subsections.]
10.1 Signatures
DECLARANT / PATIENT
Signature: ____
Print Name: ____
Date: _______
ATTENDING PRACTITIONER (Physician or APRN)
Signature: ____
Print Name: ____
License No.: _______
Date: __________
Option A: Two (2) Adult Witnesses
We, the undersigned witnesses, certify that the Declarant is personally known to us, appeared to be of sound mind and acting voluntarily, and signed or acknowledged the foregoing Directive in our presence.
-
Witness #1
• Signature: _____
• Printed Name: ____
• Address: ____
• Date: _______ -
Witness #2
• Signature: _____
• Printed Name: ____
• Address: ____
• Date: _______
Option B: Notarization
State of Wyoming )
County of _ ) ss.
On this ___ day of ____, 20__, before me, the undersigned Notarial Officer, personally appeared [Declarant Name], known to me or satisfactorily proven to be the person whose name is subscribed to the within instrument, and acknowledged that he/she executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
Notary Public Signature: ___
Notary Name (printed): ____
My Commission Expires: _______
[SEAL]
[// GUIDANCE: Counsel should verify the latest Wyoming Department of Health form requirements and EMS protocols before finalizing. Consider providing Declarant with an approved DNR bracelet/necklace for field recognition.]