MINNESOTA OUT-OF-HOSPITAL

DO NOT RESUSCITATE / DO NOT INTUBATE ORDER

AND HEALTH CARE DIRECTIVE

[// GUIDANCE: This template merges Minnesota’s statutory Health Care Directive requirements (Minn. Stat. ch. 145C) with the EMS-recognized DNR/DNI provider order framework. Customize bracketed fields, confirm all medical details with the attending clinician, and attach any facility-specific rider (e.g., POLST).]

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

1. DOCUMENT HEADER

1.1 Title & Parties
This Out-of-Hospital Do Not Resuscitate / Do Not Intubate Order and Health Care Directive (the “Directive”) is executed by [FULL LEGAL NAME OF PRINCIPAL] (the “Principal”), born [DOB], residing at [ADDRESS], and acknowledged by the undersigned Attending Clinician (the “Clinician”).

1.2 Effective Date & Jurisdiction
This Directive is effective on the later of (a) the date signed by the Principal (or the Principal’s authorized Health Care Agent) and (b) the date countersigned by the Clinician (the “Effective Date”). It is governed by the health-care-decision laws of the State of Minnesota.

1.3 Recitals
A. Minnesota law permits competent adults to direct the withholding of cardiopulmonary resuscitation (“CPR”) and advanced airway management outside the hospital setting.
B. Principal desires to refuse resuscitative measures in the event of cardiopulmonary arrest and to authorize medical personnel to comply with such refusal.
C. Clinician has reviewed the Principal’s medical condition and concurs that the DNR/DNI order herein is medically appropriate.

2. DEFINITIONS

“Agent” means the health care agent(s) named in §3.5.
“Cardiopulmonary Arrest” means the absence of spontaneous circulation and breathing.
“Clinician” means the Minnesota-licensed physician, APRN, or physician assistant signing this Directive.
“DNR” means a do-not-resuscitate order (no chest compressions, defibrillation, or cardio-active drugs).
“DNI” means a do-not-intubate order (no endotracheal intubation or advanced airway).
“EMS Personnel” means emergency medical services providers licensed under Minnesota law.
“Good-Faith Reliance” has the meaning set forth in §7.2.
“Principal” means the individual who is the subject of this Directive.
“Revocation” means any act described in §6.2 that nullifies this Directive.

[// GUIDANCE: Include additional definitions only if used elsewhere in the document.]

3. OPERATIVE PROVISIONS

3.1 Provider Orders. The Clinician hereby orders that, upon Cardiopulmonary Arrest, EMS Personnel and all other health-care providers SHALL:
(a) withhold CPR;
(b) withhold defibrillation;
(c) withhold endotracheal intubation or advanced airway placement;
(d) provide comfort-focused care per standard protocols.

3.2 Scope of Treatment Prior to Arrest. Prior to Cardiopulmonary Arrest, the Principal consents to all medically indicated treatments OTHER THAN invasive airway placement, unless explicitly authorized in writing after the Effective Date.

3.3 Documentation & Portability.
(a) The original Directive shall accompany the Principal when transferred between care settings.
(b) A photocopy, facsimile, electronic, or bracelet/necklace representation invoking this Directive shall be deemed an operative original.

3.4 EMS Recognition. EMS Personnel acting in reliance on this Directive shall honor the orders herein in any out-of-hospital setting within Minnesota.

3.5 Appointment of Health Care Agent (Optional but Recommended).
Principal hereby appoints [NAME OF AGENT], [CONTACT INFO] as first agent, and [NAME OF SUCCESSOR AGENT] as successor agent, with full authority to:
(a) reaffirm, modify, or revoke this Directive; and
(b) consent to or refuse medical treatment consistent with the Principal’s expressed wishes.

3.6 Duration. This Directive remains in force until revoked under §6.2 or superseded by a later-dated, valid directive.

4. REPRESENTATIONS & WARRANTIES

4.1 Principal’s Representations. Principal represents that:
(a) Principal is mentally competent and executing this Directive voluntarily;
(b) Principal has discussed the implications of a DNR/DNI order with the Clinician;
(c) No undue influence, duress, or fraud has been exerted.

4.2 Clinician’s Representations. Clinician warrants that:
(a) Clinician is duly licensed and authorized to issue medical orders in Minnesota;
(b) The medical indications for DNR/DNI have been reviewed with the Principal (or Agent);
(c) Clinician will promptly enter the order into the Principal’s medical record.

4.3 Witness/Notary Representation (see §10). Each witness/notary affirms the execution formalities required by Minnesota law have been satisfied.

5. COVENANTS & RESTRICTIONS

5.1 Principal’s Covenants. Principal shall:
(a) Keep the most recent original or copy of this Directive readily accessible;
(b) Wear, if desired, a Minnesota-approved DNR identification bracelet or necklace;
(c) Inform family members and caregivers of the Directive’s existence.

5.2 Clinician’s Covenants. Clinician shall:
(a) Review the Directive’s continued appropriateness at each significant change in the Principal’s health status;
(b) Re-issue or update the order if required by Minnesota Department of Health regulations.

5.3 Facility Obligations. Any admitting facility shall incorporate the Directive into the Principal’s chart and communicate it to attending staff at shift change.

6. DEFAULT, REVOCATION & REMEDIES

6.1 Events of Default. Any violation of the orders in §3.1 constitutes a default.

6.2 Revocation. This Directive may be revoked at any time by:
(a) the Principal, orally or in writing;
(b) the Agent, if authorized and the Principal lacks decision-making capacity;
(c) a subsequent, validly-executed health care directive expressly revoking DNR/DNI instructions;
(d) physical destruction of the Directive by the Principal (e.g., tearing, burning).

6.3 Notice & Cure. Upon receiving credible notice of revocation, providers must immediately resume full resuscitative measures unless a new order is issued.

6.4 Remedies.
(a) Injunctive Relief – see §8.2.
(b) Statutory damages or disciplinary action as allowed under Minnesota law for willful disregard of a valid directive.
(c) Attorneys’ Fees – prevailing party in enforcement action entitled to reasonable fees and costs.

7. RISK ALLOCATION

7.1 Provider Indemnification. The Principal (and Principal’s estate) agrees to defend, indemnify, and hold harmless any health-care provider or EMS Personnel who, in Good-Faith Reliance on this Directive, withholds or ceases resuscitative efforts.

7.2 Limitation of Liability. No provider acting in Good-Faith Reliance shall be liable for civil, criminal, or administrative penalties, except for acts of gross negligence or willful misconduct.

7.3 Insurance. Providers shall maintain professional liability coverage as required by Minnesota law; no separate insurance is mandated by this Directive.

7.4 Force Majeure. Providers are excused from compliance if circumstances beyond their reasonable control (e.g., mass-casualty incident) render compliance impossible.

8. DISPUTE RESOLUTION

8.1 Governing Law. This Directive is governed exclusively by Minnesota health-care-decision statutes and related regulations.

8.2 Injunctive Relief. Because monetary damages are inadequate to remedy noncompliance, the Principal (or Agent) may seek temporary, preliminary, and/or permanent injunctive relief to enforce the orders herein.

8.3 Alternative Dispute Mechanisms. Arbitration, jury waiver, and forum-selection clauses are intentionally omitted as not applicable to this Directive.

9. GENERAL PROVISIONS

9.1 Amendments & Waivers. Any amendment must satisfy the same execution formalities as this Directive. No waiver of any provision shall be effective unless in a writing executed by the waiving party.

9.2 Assignment. Rights and duties under this Directive are personal and non-assignable.

9.3 Severability. If any provision is held invalid, the remaining provisions remain enforceable to the fullest extent permitted.

9.4 Integration. This Directive constitutes the entire understanding regarding resuscitative measures and supersedes all prior inconsistent writings.

9.5 Copies & Electronic Signatures. Counterparts, telecopies, and electronic signatures (including secure digital and tele-health signatures) are legally effective.

10. EXECUTION BLOCK

[// GUIDANCE: Choose EITHER (A) two witnesses OR (B) a notary. Do not use both.]

10.1 Principal / Agent Signature

If Principal lacks capacity at signing:

10.2 Attending Clinician Signature (Required for EMS Recognition)

10.3 Witness OPTION (Two Adult Witnesses)

—OR—

10.4 Notary OPTION

State of Minnesota )
County of ____ ) ss.

On this ___ day of _, 20, before me, a Notary Public, personally appeared [NAME OF SIGNER], known to me or satisfactorily proven to be the person whose name is subscribed to the foregoing instrument and acknowledged that he/she executed the same for the purposes therein contained.

Notary Public: ____
My Commission Expires: ___

[// GUIDANCE:

1. Provide a wallet card or bracelet referencing this Directive.
2. Enter the signed Directive into the Principal’s electronic medical record.
3. Review annually or upon any substantive change in health status.
   ]

END OF DOCUMENT