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INDIANA STATUTES AND CODES

CHAPTER 5. OUT OF HOSPITAL DO NOT RESUSCITATE DECLARATIONS

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IC 16-36-5 Chapter 5. Out of Hospital Do Not Resuscitate Declarations IC 16-36-5-1 "Cardiopulmonary resuscitation" or "CPR" defined Sec. 1. As used in this chapter, "cardiopulmonary resuscitation" or "CPR" means cardiopulmonary resuscitation or a component of cardiopulmonary resuscitation, including: (1) cardiac compression; (2) endotracheal intubation and other advanced airway management; (3) artificial ventilation; (4) defibrillation; (5) administration of cardiac resuscitation medications; and (6) related procedures. The term does not include the Heimlich maneuver or a similar procedure used to expel an obstruction from the throat. As added by P.L.148-1999, SEC.12. IC 16-36-5-2 "Competent witness" defined Sec. 2. As used in this chapter, "competent witness" means a person at least eighteen (18) years of age who is not: (1) the person who signed an out of hospital DNR declaration on behalf of and at the direction of the declarant; (2) a parent, spouse, or child of the declarant; (3) entitled to any part of the declarant's estate; or (4) directly financially responsible for the declarant's medical care. For purposes of subdivision (3), a person is not considered to be entitled to any part of the declarant's estate solely by virtue of being nominated as a personal representative or as the attorney for the estate in the declarant's will. As added by P.L.148-1999, SEC.12. IC 16-36-5-3 "Declarant" defined Sec. 3. As used in this chapter, "declarant" means a person: (1) who has executed an out of hospital DNR declaration under section 11(a) of this chapter; or (2) for whom a representative has executed an out of hospital DNR declaration under section 11(b) of this chapter; and for whom an out of hospital DNR order has been written under section 12 of this chapter. As added by P.L.148-1999, SEC.12. IC 16-36-5-4 "DNR" defined Sec. 4. As used in this chapter, "DNR" means do not resuscitate. As added by P.L.148-1999, SEC.12. IC 16-36-5-5 "Out of hospital" defined Sec. 5. As used in this chapter, "out of hospital" refers to a location other than: (1) an acute care hospital licensed under IC 16-21-2; or (2) a health facility licensed under IC 16-28. As added by P.L.148-1999, SEC.12. IC 16-36-5-6 "Out of hospital DNR declaration and order" defined Sec. 6. As used in this chapter, "out of hospital DNR declaration and order" means a document executed under sections 11 and 12 of this chapter. As added by P.L.148-1999, SEC.12. IC 16-36-5-7 "Out of hospital DNR identification device" defined Sec. 7. As used in this chapter, "out of hospital DNR identification device" means a device developed by the emergency medical services commission under section 17 of this chapter. As added by P.L.148-1999, SEC.12. IC 16-36-5-8 "Qualified person" defined Sec. 8. As used in this chapter, "qualified person" means an individual certified as a qualified person under section 10 of this chapter. As added by P.L.148-1999, SEC.12. IC 16-36-5-9 "Representative" defined Sec. 9. As used in this chapter, "representative" means a person's: (1) legal guardian or other court appointed representative responsible for making health care decisions for the person; (2) health care representative under IC 16-36-1; or (3) attorney in fact for health care appointed under IC 30-5-5-16. As added by P.L.148-1999, SEC.12. IC 16-36-5-10 Certification as qualified person Sec. 10. An attending physician may certify that a patient is a qualified person if the attending physician determines, in accordance with reasonable medical standards, that one (1) of the following conditions is met: (1) The person has a terminal condition (as defined in IC 16-36-4-5). (2) The person has a medical condition such that, if the person were to suffer cardiac or pulmonary failure, resuscitation would be unsuccessful or within a short period the person would experience repeated cardiac or pulmonary failure resulting in death. As added by P.L.148-1999, SEC.12. IC 16-36-5-11 Execution of declaration Sec. 11. (a) A person who is of sound mind and at least eighteen (18) years of age may execute an out of hospital DNR declaration. (b) A person's representative may execute an out of hospital DNR declaration for the person under this chapter only if the person is: (1) at least eighteen (18) years of age; and (2) incompetent. (c) An out of hospital DNR declaration must meet the following conditions: (1) Be voluntary. (2) Be in writing. (3) Be signed by the person making the declaration or by another person in the declarant's presence and at the declarant's express direction. (4) Be dated. (5) Be signed in the presence of at least two (2) competent witnesses. (d) An out of hospital DNR declaration must be issued on the form specified in section 15 of this chapter. As added by P.L.148-1999, SEC.12. IC 16-36-5-12 Issuance of DNR order Sec. 12. An out of hospital DNR order: (1) may be issued only by the declarant's attending physician; and (2) may be issued only if both of the following apply: (A) The attending physician has determined the patient is a qualified person. (B) The patient has executed an out of hospital DNR declaration under section 11 of this chapter. As added by P.L.148-1999, SEC.12. IC 16-36-5-13 Transfer of patient to another physician Sec. 13. (a) An attending physician who does not issue an out of hospital DNR order for a patient who is a qualified person may transfer the patient to another physician, who may issue an out of hospital DNR order, unless: (1) the attending physician has reason to believe the patient's declaration was not validly executed, or there is evidence the patient no longer intends the declaration to be enforced; and (2) the patient is unable to validate the declaration. (b) Notwithstanding section 10 of this chapter, if an attending physician, after reasonable investigation, does not find any other physician willing to honor the patient's out of hospital DNR declaration and issue an out of hospital DNR order, the attending physician may refuse to issue an out of hospital DNR order. (c) If the attending physician does not transfer a patient under subsection (a), the attending physician may attempt to ascertain the patient's intent and attempt to determine the validity of the declaration by consulting with any of the following individuals who are reasonably available, willing, and competent to act: (1) A court appointed guardian of the patient, if one has been appointed. This subdivision does not require the appointment of a guardian so that a treatment decision may be made under this section. (2) A person designated by the patient in writing to make a treatment decision. (3) The patient's spouse. (4) An adult child of the patient or a majority of any adult children of the patient who are reasonably available for consultation. (5) An adult sibling of the patient or a majority of any adult siblings of the patient who are reasonably available for consultation. (6) The patient's clergy. (7) Another person who has firsthand knowledge of the patient's intent. (d) The individuals described in subsection (c)(1) through (c)(7) shall act in the best interest of the patient and shall follow the patient's express or implied intent, if known. (e) The attending physician acting under subsection (c) shall list the names of the individuals described in subsection (c) who were consulted and include the information received in the patient's medical file. (f) If the attending physician determines from the information received under subsection (c) that the patient intended to execute a valid out of hospital DNR declaration, the attending physician may: (1) issue an out of hospital DNR order, with the concurrence of at least one (1) physician documented in the patient's medical file; or (2) request a court to appoint a guardian for the patient to make the consent decision on behalf of the patient. (g) An out of hospital DNR order must be issued on the form specified in section 15 of this chapter. As added by P.L.148-1999, SEC.12. IC 16-36-5-14 Effect of declaration during pregnancy Sec. 14. An out of hospital DNR declaration and order of a declarant known to be pregnant has no effect during the declarant's pregnancy. As added by P.L.148-1999, SEC.12. IC 16-36-5-15 Form Sec. 15. An out of hospital DNR declaration and order must be in substantially the following form: OUT OF HOSPITAL DO NOT RESUSCITATE DECLARATION AND ORDER This declaration and order is effective on the date of execution and remains in effect until the death of the declarant or revocation. OUT OF HOSPITAL DO NOT RESUSCITATE DECLARATION Declaration made this ____ day of __________. I, _____________, being of sound mind and at least eighteen (18) years of age, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below. I declare: My attending physician has certified that I am a qualified person, meaning that I have a terminal condition or a medical condition such that, if I suffer cardiac or pulmonary failure, resuscitation would be unsuccessful or within a short period I would experience repeated cardiac or pulmonary failure resulting in death. I direct that, if I experience cardiac or pulmonary failure in a location other than an acute care hospital or a health facility, cardiopulmonary resuscitation procedures be withheld or withdrawn and that I be permitted to die naturally. My medical care may include any medical procedure necessary to provide me with comfort care or to alleviate pain. I understand that I may revoke this out of hospital DNR declaration at any time by a signed and dated writing, by destroying or canceling this document, or by communicating to health care providers at the scene the desire to revoke this declaration. I understand the full import of this declaration. Signed___________________________________ Printed name______________________________ _________________________________________ City and State of Residence___________________ The declarant is personally known to me, and I believe the declarant to be of sound mind. I did not sign the declarant's signature above, for, or at the direction of, the declarant. I am not a parent, spouse, or child of the declarant. I am not entitled to any part of the declarant's estate or directly financially responsible for the declarant's medical care. I am competent and at least eighteen (18) years of age. Witness____________Printed name___________Date__________ Witness____________Printed name___________Date__________ OUT OF HOSPITAL DO NOT RESUSCITATE ORDER I,___________________, the attending physician of _________________, have certified the declarant as a qualified person to make an out of hospital DNR declaration, and I order health care providers having actual notice of this out of hospital DNR declaration and order not to initiate or continue cardiopulmonary resuscitation procedures on behalf of the declarant, unless the out of hospital DNR declaration is revoked. Signed_____________________Date__________ Printed name______________________________ Medical license number_____________________ As added by P.L.148-1999, SEC.12. IC 16-36-5-16 Copies of declaration and order Sec. 16. Copies of the out of hospital DNR declaration and order must be kept: (1) by the declarant's attending physician in the declarant's medical file; and (2) by the declarant or the declarant's representative. As added by P.L.148-1999, SEC.12. IC 16-36-5-17 Identification devices Sec. 17. (a) The emergency medical services commission shall develop an out of hospital DNR identification device that must be: (1) a necklace or bracelet; and (2) inscribed with: (A) the declarant's name; (B) the declarant's date of birth; and (C) the words "Do Not Resuscitate". (b) An out of hospital DNR identification device may be created for a declarant only after an out of hospital DNR declaration and order has been executed by a declarant and an attending physician. (c) The device developed under subsection (a) is not a substitute for the out of hospital DNR declaration and order. As added by P.L.148-1999, SEC.12. IC 16-36-5-18 Revocation Sec. 18. (a) A declarant may at any time revoke an out of hospital DNR declaration and order by any of the following: (1) A signed, dated writing. (2) Physical cancellation or destruction of the declaration and order by the declarant or another in the declarant's presence and at the declarant's direction. (3) An oral expression by the declarant of intent to revoke. (b) A declarant's representative may revoke an out of hospital DNR declaration and order under this chapter only if the declarant is incompetent. (c) A revocation is effective upon communication to a health care provider. (d) A health care provider to whom the revocation of an out of hospital DNR declaration and order is communicated shall immediately notify the declarant's attending physician, if known, of the revocation. (e) An attending physician notified of the revocation of an out of hospital DNR declaration and order shall immediately: (1) add the revocation to the declarant's medical file, noting the time, date, and place of revocation, if known, and the time, date, and place that the physician was notified; (2) cancel the out of hospital DNR declaration and order by entering the word "VOID" on each page of the out of hospital DNR declaration and order in the declarant's medical file; and (3) notify any health care facility staff responsible for the declarant's care of the revocation. As added by P.L.148-1999, SEC.12. IC 16-36-5-19 Health care provider duties Sec. 19. (a) A health care provider shall withhold or discontinue CPR to a patient in an out of hospital location if the health care provider has actual knowledge of: (1) an original or a copy of a signed out of hospital DNR declaration and order executed by the patient; or (2) an out of hospital DNR identification device worn by the patient or in the patient's possession. (b) A health care provider shall disregard an out of hospital DNR declaration and order and perform CPR if: (1) the declarant is conscious and states a desire for resuscitative measures; (2) the health care provider believes in good faith that the out of hospital DNR declaration and order has been revoked; (3) the health care provider is ordered by the attending physician to disregard the out of hospital DNR declaration and order; or (4) the health care provider believes in good faith that the out of hospital DNR declaration and order must be disregarded to avoid verbal or physical confrontation at the scene. (c) A health care provider transporting a declarant shall document on the transport form: (1) the presence of an out of hospital DNR declaration and order; (2) the attending physician's name; and (3) the date the out of hospital DNR declaration and order was signed. (d) An out of hospital DNR identification device must accompany a declarant whenever the declarant is transported. As added by P.L.148-1999, SEC.12. IC 16-36-5-20 Health care provider liability Sec. 20. A health care provider who in good faith and in accordance with reasonable medical standards: (1) participates in the withholding or withdrawal of CPR from a declarant: (A) by whom an out of hospital DNR declaration and order has been executed under this chapter; or (B) who has revoked an out of hospital DNR declaration and order when the health care provider has no notice of the revocation; or (2) provides CPR to a declarant: (A) when the health care provider has no notice of the out of hospital DNR declaration and order; or (B) after a revocation of an out of hospital DNR declaration and order; is not subject to criminal or civil liability and may not be found to have committed an act of unprofessional conduct. As added by P.L.148-1999, SEC.12. IC 16-36-5-21 Presumption of validity Sec. 21. (a) If a declarant is incompetent at the time of the decision to withhold or withdraw CPR, an out of hospital DNR declaration and order executed under this chapter is presumed to be valid. (b) For purposes of this chapter, a health care provider may presume in the absence of actual notice to the contrary that the declarant was of sound mind when the out of hospital DNR declaration and order was executed. (c) The fact that a declarant executed an out of hospital declaration may not be considered as an indication of the declarant's mental incompetency. As added by P.L.148-1999, SEC.12. IC 16-36-5-22 Petition for review Sec. 22. (a) A person may challenge the validity of an out of hospital DNR declaration and order by filing a petition for review in a court in the county in which the declarant resides. (b) A petition filed under subsection (a) must include the name and address of the declarant's attending physician. (c) A court in which a petition is filed under subsection (a) may declare an out of hospital DNR declaration and order void if the court finds that the out of hospital DNR declaration and order was executed: (1) when the declarant was incapacitated due to insanity, mental illness, mental deficiency, duress, undue influence, fraud, excessive use of drugs, confinement, or other disability; (2) contrary to the declarant's wishes; or (3) when the declarant was not a qualified person. (d) If a court finds that the out of hospital DNR declaration and order is void, the court shall cause notice of the finding to be sent to the declarant's attending physician. (e) Upon notice under subsection (d), the declarant's attending physician shall follow the procedures under section 18(e) of this chapter. As added by P.L.148-1999, SEC.12. IC 16-36-5-23 Effect upon life insurance policies Sec. 23. (a) A death caused by the withholding or withdrawal of CPR under this chapter does not constitute a suicide. (b) The execution of an out of hospital DNR declaration and order under this chapter does not affect the sale, issuance, or terms of a life insurance policy. (c) A policy of life insurance is not legally impaired or invalidated by the execution of an out of hospital DNR declaration and order or by the withholding or withdrawal of CPR from an insured declarant, notwithstanding any term of the policy to the contrary. (d) An out of hospital DNR declaration and order may not be considered in the establishment of insurance premiums for a declarant. (e) A person may not require another person to execute an out of hospital DNR declaration and order as a condition for being insured for or receiving health care services. (f) This chapter does not impair or supersede any legal right or legal responsibility that a person may have to effect the withholding or withdrawal of CPR in a lawful manner. As added by P.L.148-1999, SEC.12. IC 16-36-5-24 Intent of person without declaration not presumed Sec. 24. This chapter does not create any presumption concerning the intent of a person who has not executed an out of hospital DNR declaration and order to consent to the withholding or withdrawal of CPR if a terminal condition exists, or if a medical condition exists such that the outcome of performing CPR would have the results specified in section 10(2) of this chapter. As added by P.L.148-1999, SEC.12. IC 16-36-5-25 Euthanasia not authorized Sec. 25. This chapter does not authorize euthanasia or any affirmative or deliberate act or omission to end life other than to permit the natural process of dying. As added by P.L.148-1999, SEC.12. IC 16-36-5-26 Effect upon chain of proximate cause Sec. 26. The act of withholding or withdrawing CPR, when done under: (1) an out of hospital DNR declaration and order issued under this chapter; (2) a court order or decision of a court appointed guardian; or (3) a good faith medical decision by the attending physician that the patient has a terminal illness; is not an intervening force and does not affect the chain of proximate cause between the conduct of a person that placed the patient in a terminal condition and the patient's death. As added by P.L.148-1999, SEC.12. IC 16-36-5-27 Destruction of declaration; forgery of revocation Sec. 27. A person who knowingly or intentionally: (1) physically cancels or destroys an out of hospital DNR declaration and order without the declarant's consent; (2) physically cancels or destroys an out of hospital DNR declaration and order without the declarant's representative's consent if the declarant is incompetent; or (3) falsifies or forges a revocation of another person's out of hospital DNR declaration and order; commits a Class B misdemeanor. As added by P.L.148-1999, SEC.12. IC 16-36-5-28 Deception with intent to cause withholding of CPR Sec. 28. (a) A person who knowingly or intentionally: (1) falsifies or forges the out of hospital DNR declaration and order of another person with intent to cause the withholding or withdrawal of CPR; or (2) conceals or withholds personal knowledge of the revocation of an out of hospital DNR declaration and order with intent to cause the withholding or withdrawal of CPR; commits a Class C felony. (b) A person who commits an offense described in this section is subject to IC 29-1-2-12.1. As added by P.L.148-1999, SEC.12.
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  • IC 16-36-5
         Chapter 5. Out of Hospital Do Not Resuscitate Declarations

    IC 16-36-5-1
    "Cardiopulmonary resuscitation" or "CPR" defined
        
    Sec. 1. As used in this chapter, "cardiopulmonary resuscitation" or "CPR" means cardiopulmonary resuscitation or a component of cardiopulmonary resuscitation, including:
            (1) cardiac compression;
            (2) endotracheal intubation and other advanced airway management;
            (3) artificial ventilation;
            (4) defibrillation;
            (5) administration of cardiac resuscitation medications; and
            (6) related procedures.
    The term does not include the Heimlich maneuver or a similar procedure used to expel an obstruction from the throat.
    As added by P.L.148-1999, SEC.12.

    IC 16-36-5-2
    "Competent witness" defined
        
    Sec. 2. As used in this chapter, "competent witness" means a person at least eighteen (18) years of age who is not:
            (1) the person who signed an out of hospital DNR declaration on behalf of and at the direction of the declarant;
            (2) a parent, spouse, or child of the declarant;
            (3) entitled to any part of the declarant's estate; or
            (4) directly financially responsible for the declarant's medical care.
    For purposes of subdivision (3), a person is not considered to be entitled to any part of the declarant's estate solely by virtue of being nominated as a personal representative or as the attorney for the estate in the declarant's will.
    As added by P.L.148-1999, SEC.12.

    IC 16-36-5-3
    "Declarant" defined
        
    Sec. 3. As used in this chapter, "declarant" means a person:
            (1) who has executed an out of hospital DNR declaration under section 11(a) of this chapter; or
            (2) for whom a representative has executed an out of hospital DNR declaration under section 11(b) of this chapter;
    and for whom an out of hospital DNR order has been written under section 12 of this chapter.
    As added by P.L.148-1999, SEC.12.

    IC 16-36-5-4
    "DNR" defined
        
    Sec. 4. As used in this chapter, "DNR" means do not resuscitate.
    As added by P.L.148-1999, SEC.12.
    IC 16-36-5-5
    "Out of hospital" defined
        
    Sec. 5. As used in this chapter, "out of hospital" refers to a location other than:
            (1) an acute care hospital licensed under IC 16-21-2; or
            (2) a health facility licensed under IC 16-28.
    As added by P.L.148-1999, SEC.12.

    IC 16-36-5-6
    "Out of hospital DNR declaration and order" defined
        
    Sec. 6. As used in this chapter, "out of hospital DNR declaration and order" means a document executed under sections 11 and 12 of this chapter.
    As added by P.L.148-1999, SEC.12.

    IC 16-36-5-7
    "Out of hospital DNR identification device" defined
        
    Sec. 7. As used in this chapter, "out of hospital DNR identification device" means a device developed by the emergency medical services commission under section 17 of this chapter.
    As added by P.L.148-1999, SEC.12.

    IC 16-36-5-8
    "Qualified person" defined
        
    Sec. 8. As used in this chapter, "qualified person" means an individual certified as a qualified person under section 10 of this chapter.
    As added by P.L.148-1999, SEC.12.

    IC 16-36-5-9
    "Representative" defined
        
    Sec. 9. As used in this chapter, "representative" means a person's:
            (1) legal guardian or other court appointed representative responsible for making health care decisions for the person;
            (2) health care representative under IC 16-36-1; or
            (3) attorney in fact for health care appointed under IC 30-5-5-16.
    As added by P.L.148-1999, SEC.12.

    IC 16-36-5-10
    Certification as qualified person
        
    Sec. 10. An attending physician may certify that a patient is a qualified person if the attending physician determines, in accordance with reasonable medical standards, that one (1) of the following conditions is met:
            (1) The person has a terminal condition (as defined in IC 16-36-4-5).
            (2) The person has a medical condition such that, if the person were to suffer cardiac or pulmonary failure, resuscitation would be unsuccessful or within a short period the person would

    experience repeated cardiac or pulmonary failure resulting in death.
    As added by P.L.148-1999, SEC.12.

    IC 16-36-5-11
    Execution of declaration
        
    Sec. 11. (a) A person who is of sound mind and at least eighteen (18) years of age may execute an out of hospital DNR declaration.
        (b) A person's representative may execute an out of hospital DNR declaration for the person under this chapter only if the person is:
            (1) at least eighteen (18) years of age; and
            (2) incompetent.
        (c) An out of hospital DNR declaration must meet the following conditions:
            (1) Be voluntary.
            (2) Be in writing.
            (3) Be signed by the person making the declaration or by another person in the declarant's presence and at the declarant's express direction.
            (4) Be dated.
            (5) Be signed in the presence of at least two (2) competent witnesses.
        (d) An out of hospital DNR declaration must be issued on the form specified in section 15 of this chapter.
    As added by P.L.148-1999, SEC.12.

    IC 16-36-5-12

    Issuance of DNR order
        
    Sec. 12. An out of hospital DNR order:
            (1) may be issued only by the declarant's attending physician; and
            (2) may be issued only if both of the following apply:
                (A) The attending physician has determined the patient is a qualified person.
                (B) The patient has executed an out of hospital DNR declaration under section 11 of this chapter.
    As added by P.L.148-1999, SEC.12.

    IC 16-36-5-13
    Transfer of patient to another physician
        
    Sec. 13. (a) An attending physician who does not issue an out of hospital DNR order for a patient who is a qualified person may transfer the patient to another physician, who may issue an out of hospital DNR order, unless:
            (1) the attending physician has reason to believe the patient's declaration was not validly executed, or there is evidence the patient no longer intends the declaration to be enforced; and
            (2) the patient is unable to validate the declaration.
        (b) Notwithstanding section 10 of this chapter, if an attending physician, after reasonable investigation, does not find any other

    physician willing to honor the patient's out of hospital DNR declaration and issue an out of hospital DNR order, the attending physician may refuse to issue an out of hospital DNR order.
        (c) If the attending physician does not transfer a patient under subsection (a), the attending physician may attempt to ascertain the patient's intent and attempt to determine the validity of the declaration by consulting with any of the following individuals who are reasonably available, willing, and competent to act:
            (1) A court appointed guardian of the patient, if one has been appointed. This subdivision does not require the appointment of a guardian so that a treatment decision may be made under this section.
            (2) A person designated by the patient in writing to make a treatment decision.
            (3) The patient's spouse.
            (4) An adult child of the patient or a majority of any adult children of the patient who are reasonably available for consultation.
            (5) An adult sibling of the patient or a majority of any adult siblings of the patient who are reasonably available for consultation.
            (6) The patient's clergy.
            (7) Another person who has firsthand knowledge of the patient's intent.
        (d) The individuals described in subsection (c)(1) through (c)(7) shall act in the best interest of the patient and shall follow the patient's express or implied intent, if known.
        (e) The attending physician acting under subsection (c) shall list the names of the individuals described in subsection (c) who were consulted and include the information received in the patient's medical file.
        (f) If the attending physician determines from the information received under subsection (c) that the patient intended to execute a valid out of hospital DNR declaration, the attending physician may:
            (1) issue an out of hospital DNR order, with the concurrence of at least one (1) physician documented in the patient's medical file; or
            (2) request a court to appoint a guardian for the patient to make the consent decision on behalf of the patient.
        (g) An out of hospital DNR order must be issued on the form specified in section 15 of this chapter.
    As added by P.L.148-1999, SEC.12.

    IC 16-36-5-14
    Effect of declaration during pregnancy
        
    Sec. 14. An out of hospital DNR declaration and order of a declarant known to be pregnant has no effect during the declarant's pregnancy.
    As added by P.L.148-1999, SEC.12.
    IC 16-36-5-15
    Form
        
    Sec. 15. An out of hospital DNR declaration and order must be in substantially the following form:

    OUT OF HOSPITAL DO NOT RESUSCITATE DECLARATION

    AND ORDER
    This declaration and order is effective on the date of execution and remains in effect until the death of the declarant or revocation.

    OUT OF HOSPITAL DO NOT RESUSCITATE DECLARATION


    Declaration made this ____ day of __________. I, _____________, being of sound mind and at least eighteen (18) years of age, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below. I declare:
        My attending physician has certified that I am a qualified person, meaning that I have a terminal condition or a medical condition such that, if I suffer cardiac or pulmonary failure, resuscitation would be unsuccessful or within a short period I would experience repeated cardiac or pulmonary failure resulting in death.
        I direct that, if I experience cardiac or pulmonary failure in a location other than an acute care hospital or a health facility, cardiopulmonary resuscitation procedures be withheld or withdrawn and that I be permitted to die naturally. My medical care may include any medical procedure necessary to provide me with comfort care or to alleviate pain.
        I understand that I may revoke this out of hospital DNR declaration at any time by a signed and dated writing, by destroying or canceling this document, or by communicating to health care providers at the scene the desire to revoke this declaration.
        I understand the full import of this declaration.
                        Signed___________________________________
                        Printed name______________________________
                        _________________________________________
                        City and State of Residence___________________
        The declarant is personally known to me, and I believe the declarant to be of sound mind. I did not sign the declarant's signature above, for, or at the direction of, the declarant. I am not a parent, spouse, or child of the declarant. I am not entitled to any part of the declarant's estate or directly financially responsible for the declarant's medical care. I am competent and at least eighteen (18) years of age.
    Witness____________Printed name___________Date__________
    Witness____________Printed name___________Date__________

    OUT OF HOSPITAL DO NOT RESUSCITATE ORDER


        I,___________________, the attending physician of _________________, have certified the declarant as a qualified person to make an out of hospital DNR declaration, and I order health care providers having actual notice of this out of hospital DNR declaration and order not to initiate or continue cardiopulmonary resuscitation procedures on behalf of the declarant,

    unless the out of hospital DNR declaration is revoked.
                        Signed_____________________Date__________
                        Printed name______________________________
                        Medical license number_____________________
    As added by P.L.148-1999, SEC.12.

    IC 16-36-5-16
    Copies of declaration and order
        
    Sec. 16. Copies of the out of hospital DNR declaration and order must be kept:
            (1) by the declarant's attending physician in the declarant's medical file; and
            (2) by the declarant or the declarant's representative.
    As added by P.L.148-1999, SEC.12.

    IC 16-36-5-17
    Identification devices
        
    Sec. 17. (a) The emergency medical services commission shall develop an out of hospital DNR identification device that must be:
            (1) a necklace or bracelet; and
            (2) inscribed with:
                (A) the declarant's name;
                (B) the declarant's date of birth; and
                (C) the words "Do Not Resuscitate".
        (b) An out of hospital DNR identification device may be created for a declarant only after an out of hospital DNR declaration and order has been executed by a declarant and an attending physician.
        (c) The device developed under subsection (a) is not a substitute for the out of hospital DNR declaration and order.
    As added by P.L.148-1999, SEC.12.

    IC 16-36-5-18
    Revocation
        
    Sec. 18. (a) A declarant may at any time revoke an out of hospital DNR declaration and order by any of the following:
            (1) A signed, dated writing.
            (2) Physical cancellation or destruction of the declaration and order by the declarant or another in the declarant's presence and at the declarant's direction.
            (3) An oral expression by the declarant of intent to revoke.
        (b) A declarant's representative may revoke an out of hospital DNR declaration and order under this chapter only if the declarant is incompetent.
        (c) A revocation is effective upon communication to a health care provider.
        (d) A health care provider to whom the revocation of an out of hospital DNR declaration and order is communicated shall immediately notify the declarant's attending physician, if known, of the revocation.
        (e) An attending physician notified of the revocation of an out of

    hospital DNR declaration and order shall immediately:
            (1) add the revocation to the declarant's medical file, noting the time, date, and place of revocation, if known, and the time, date, and place that the physician was notified;
            (2) cancel the out of hospital DNR declaration and order by entering the word "VOID" on each page of the out of hospital DNR declaration and order in the declarant's medical file; and
            (3) notify any health care facility staff responsible for the declarant's care of the revocation.
    As added by P.L.148-1999, SEC.12.

    IC 16-36-5-19
    Health care provider duties
        
    Sec. 19. (a) A health care provider shall withhold or discontinue CPR to a patient in an out of hospital location if the health care provider has actual knowledge of:
            (1) an original or a copy of a signed out of hospital DNR declaration and order executed by the patient; or
            (2) an out of hospital DNR identification device worn by the patient or in the patient's possession.
        (b) A health care provider shall disregard an out of hospital DNR declaration and order and perform CPR if:
            (1) the declarant is conscious and states a desire for resuscitative measures;
            (2) the health care provider believes in good faith that the out of hospital DNR declaration and order has been revoked;
            (3) the health care provider is ordered by the attending physician to disregard the out of hospital DNR declaration and order; or
            (4) the health care provider believes in good faith that the out of hospital DNR declaration and order must be disregarded to avoid verbal or physical confrontation at the scene.
        (c) A health care provider transporting a declarant shall document on the transport form:
            (1) the presence of an out of hospital DNR declaration and order;
            (2) the attending physician's name; and
            (3) the date the out of hospital DNR declaration and order was signed.
        (d) An out of hospital DNR identification device must accompany a declarant whenever the declarant is transported.
    As added by P.L.148-1999, SEC.12.

    IC 16-36-5-20
    Health care provider liability
        
    Sec. 20. A health care provider who in good faith and in accordance with reasonable medical standards:
            (1) participates in the withholding or withdrawal of CPR from a declarant:
                (A) by whom an out of hospital DNR declaration and order

    has been executed under this chapter; or
                (B) who has revoked an out of hospital DNR declaration and order when the health care provider has no notice of the revocation; or
            (2) provides CPR to a declarant:
                (A) when the health care provider has no notice of the out of hospital DNR declaration and order; or
                (B) after a revocation of an out of hospital DNR declaration and order;
    is not subject to criminal or civil liability and may not be found to have committed an act of unprofessional conduct.
    As added by P.L.148-1999, SEC.12.

    IC 16-36-5-21
    Presumption of validity
        
    Sec. 21. (a) If a declarant is incompetent at the time of the decision to withhold or withdraw CPR, an out of hospital DNR declaration and order executed under this chapter is presumed to be valid.
        (b) For purposes of this chapter, a health care provider may presume in the absence of actual notice to the contrary that the declarant was of sound mind when the out of hospital DNR declaration and order was executed.
        (c) The fact that a declarant executed an out of hospital declaration may not be considered as an indication of the declarant's mental incompetency.
    As added by P.L.148-1999, SEC.12.

    IC 16-36-5-22
    Petition for review
        
    Sec. 22. (a) A person may challenge the validity of an out of hospital DNR declaration and order by filing a petition for review in a court in the county in which the declarant resides.
        (b) A petition filed under subsection (a) must include the name and address of the declarant's attending physician.
        (c) A court in which a petition is filed under subsection (a) may declare an out of hospital DNR declaration and order void if the court finds that the out of hospital DNR declaration and order was executed:
            (1) when the declarant was incapacitated due to insanity, mental illness, mental deficiency, duress, undue influence, fraud, excessive use of drugs, confinement, or other disability;
            (2) contrary to the declarant's wishes; or
            (3) when the declarant was not a qualified person.
        (d) If a court finds that the out of hospital DNR declaration and order is void, the court shall cause notice of the finding to be sent to the declarant's attending physician.
        (e) Upon notice under subsection (d), the declarant's attending physician shall follow the procedures under section 18(e) of this chapter. As added by P.L.148-1999, SEC.12.

    IC 16-36-5-23
    Effect upon life insurance policies
        
    Sec. 23. (a) A death caused by the withholding or withdrawal of CPR under this chapter does not constitute a suicide.
        (b) The execution of an out of hospital DNR declaration and order under this chapter does not affect the sale, issuance, or terms of a life insurance policy.
        (c) A policy of life insurance is not legally impaired or invalidated by the execution of an out of hospital DNR declaration and order or by the withholding or withdrawal of CPR from an insured declarant, notwithstanding any term of the policy to the contrary.
        (d) An out of hospital DNR declaration and order may not be considered in the establishment of insurance premiums for a declarant.
        (e) A person may not require another person to execute an out of hospital DNR declaration and order as a condition for being insured for or receiving health care services.
        (f) This chapter does not impair or supersede any legal right or legal responsibility that a person may have to effect the withholding or withdrawal of CPR in a lawful manner.
    As added by P.L.148-1999, SEC.12.

    IC 16-36-5-24
    Intent of person without declaration not presumed
        
    Sec. 24. This chapter does not create any presumption concerning the intent of a person who has not executed an out of hospital DNR declaration and order to consent to the withholding or withdrawal of CPR if a terminal condition exists, or if a medical condition exists such that the outcome of performing CPR would have the results specified in section 10(2) of this chapter.
    As added by P.L.148-1999, SEC.12.

    IC 16-36-5-25
    Euthanasia not authorized
        
    Sec. 25. This chapter does not authorize euthanasia or any affirmative or deliberate act or omission to end life other than to permit the natural process of dying.
    As added by P.L.148-1999, SEC.12.

    IC 16-36-5-26
    Effect upon chain of proximate cause
        
    Sec. 26. The act of withholding or withdrawing CPR, when done under:
            (1) an out of hospital DNR declaration and order issued under this chapter;
            (2) a court order or decision of a court appointed guardian; or
            (3) a good faith medical decision by the attending physician that the patient has a terminal illness; is not an intervening force and does not affect the chain of proximate cause between the conduct of a person that placed the patient in a terminal condition and the patient's death.
    As added by P.L.148-1999, SEC.12.

    IC 16-36-5-27
    Destruction of declaration; forgery of revocation
        
    Sec. 27. A person who knowingly or intentionally:
            (1) physically cancels or destroys an out of hospital DNR declaration and order without the declarant's consent;
            (2) physically cancels or destroys an out of hospital DNR declaration and order without the declarant's representative's consent if the declarant is incompetent; or
            (3) falsifies or forges a revocation of another person's out of hospital DNR declaration and order;
    commits a Class B misdemeanor.
    As added by P.L.148-1999, SEC.12.

    IC 16-36-5-28
    Deception with intent to cause withholding of CPR
        
    Sec. 28. (a) A person who knowingly or intentionally:
            (1) falsifies or forges the out of hospital DNR declaration and order of another person with intent to cause the withholding or withdrawal of CPR; or
            (2) conceals or withholds personal knowledge of the revocation of an out of hospital DNR declaration and order with intent to cause the withholding or withdrawal of CPR;
    commits a Class C felony.
        (b) A person who commits an offense described in this section is subject to IC 29-1-2-12.1.
    As added by P.L.148-1999, SEC.12.

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