DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Health Facilities and Emergency Medical Services Division IMPLEMENTATION OF CARDIOPULMONARY RESUSCITATION (CPR) DIRECTIVES BY EMERGENCY MEDICAL SERVICE PROVIDERS 6 CCR 1015-2 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________ Adopted by the Board of Health on October 16, 2019. Effective December 15, 2019. Section 1 - Purpose and Authority 1.1 Colorado law recognizes the right of an individual to accept or refuse medical treatment, including cardiopulmonary resuscitation. An individual with decision-making capacity or his/her authorized agent may use a CPR Directive to exercise the right of informed refusal of cardiopulmonary resuscitation.

1.2 Section 15-18.6-103, C.R.S., directs the State Board of Health to promulgate rules and protocols for implementation of CPR Directives by emergency medical service providers. 1.3 Nothing in these rules shall be construed to require the use of a CPR Directive by an individual. 1.4 Nothing in these rules shall be construed to restrict any other manner in which a person may make a CPR Directive, or to require the exclusive use of any specific CPR Directive form. 1.5 A CPR Directive shall not preclude evaluation by emergency medical service providers for appropriate and available medical and palliative services. 1.6 Nothing in these rules shall be construed to alter or interfere with the appropriate exercise of clinical judgment, or to alter the standards of medical practice or the principles of medical ethics. 1.7 It is the intention of these regulations to protect the welfare of patients and to respect the appropriate exercise of professional judgments made in good faith by emergency medical service providers.

Section 2 - Definitions 2.1 “Advance Directive” means an expression of treatment preferences, guidelines, or instructions regarding medical treatment made by an individual, or for an individual by that individual’s authorized agent, in advance of the need for such treatment. 2.2 “Attending Physician” means a licensed Medical Doctor (M.D.) or licensed Doctor of Osteopathy (D.O.) whom the declarant has consulted for execution of a CPR Directive. 2.3 “Authorized Agent” means any person who, pursuant to the laws of this state or any other state, is authorized to make medical treatment decisions concerning the withholding of CPR for an adult who lacks decisional capacity or for a minor, pursuant to Section 15-18.6-102, C.R.S. “Authorized Agent” includes but is not limited to a court-appointed guardian, an agent with healthcare decision-making authority appointed in a power of attorney, and/or a proxy decision-maker selected pursuant to Section 15-18.5-103, C.R.S.

1 CODE OF COLORADO REGULATIONS 6 CCR 1015-2 Health Facilities and Emergency Medical Services Division 2.4 “Board” means the State Board of Health created pursuant to Section 25-1-103, C.R.S. 2.5 “Cardiac Arrest” means the cessation of a functional heartbeat. 2.6 “Cardiopulmonary Resuscitation (CPR)” means measures to restore cardiac function or to support breathing in the event of cardiac or respiratory arrest or malfunction. “CPR” includes, but is not limited to, artificial ventilation, chest compression, delivering electric shock, placing tubes in the airway to assist breathing, or other basic and advanced resuscitative therapies. 2.7 “CPR Directive” means an advance directive pertaining to the administration of cardiopulmonary resuscitation.

2.8 “Declarant” means a person who has executed a CPR Directive. The declarant may be the individual named within the directive or the authorized agent of that named individual. 2.9 “Department” means the Colorado Department of Public Health and Environment. 2.10 “Do Not Resuscitate Order (DNR)” means a physician order to refrain from cardiopulmonary resuscitation.

2.11 “Emergency Medical Service (EMS) Provider” means an individual who holds a valid emergency medical service provider certificate or license issued by the department and includes emergency medical technician, advanced emergency medical technician, emergency medical technician intermediate, and paramedic. “EMS provider” also includes an emergency medical responder (EMR) registered with the department, in accordance with Section 25-3.5-1101, et seq., C.R.S. 2.12 “Individual” means the person who is the subject of a CPR Directive. 2.13 “Palliative Services” means specialized medical care for people with serious illnesses that is focused on providing comfort and relief from the symptoms, pain, and stress of serious illness, whatever the diagnosis. These services are appropriate at any age, and at any stage in a serious illness. Unless otherwise indicated, the term “palliative” is synonymous with the terms “comfort care”, “supportive care”, and similar terminology.

2.14 “Respiratory Arrest” (pulmonary arrest) means cessation of functional breathing. 2.15 “Resuscitation” means performing CPR.

Section 3 - General Provisions for CPR Directives 3.1 CPR Directive 3.1.1 A CPR Directive, executed pursuant to these rules, shall contain the following information:

a) name, date of birth, sex, eye and hair color, and race or ethnic background; b) if applicable, the name of the hospice program in which the individual is enrolled; c) the directive concerning the administration of CPR to the individual; d) the signature or mark of the individual or authorized agent; e) the date on which the CPR Directive was signed by the individual or authorized agent;

2 CODE OF COLORADO REGULATIONS 6 CCR 1015-2 Health Facilities and Emergency Medical Services Division f) the name, address, telephone number, and signature of the attending physician; and g) a written statement and signature(s) indicating a decision regarding tissue donation upon a patient's death, consistent with the Revised Uniform Anatomical Gift Act, Section 15-19-201, et seq., C.R.S. The written statement may be in the form authorized in Section 15-18.6-103, C.R.S.

3.1.2 A CPR Directive may be made in any other manner.

a) A CPR Directive bracelet or necklace may be regarded as valid. 3.1.3 Any CPR Directive that is apparent and immediately available to EMS providers and which directs that resuscitation not be attempted constitutes lawful authority to withhold or discontinue CPR.

3.2 Revocation of a CPR Directive 3.2.1 A CPR Directive may be revoked at any time by the declarant who is the subject of such directive or by the authorized agent for the declarant. However, only those CPR Directives executed originally by a guardian, agent, or proxy decision maker may be revoked by a guardian, agent, or proxy decision maker.

3.2.2 Family or bystanders, who are not the declarant or the declarant’s authorized agent, may not revoke a CPR directive.

Section 4 - General Protocol for Implementation of CPR Directives 4.1 Purpose 4.1.1 To provide guidance for the implementation of CPR Directives by EMS providers. 4.2. General 4.2.1 There are many ways that an individual may make his or her wishes known regarding health care, particularly end-of-life decisions.

a) This may include, but is not limited to, documents such as a living will, medical durable power of attorney, CPR Directive, or other advance directives, including those from other states.

b) Any document or item of information or instruction that clearly communicates the individual’s wishes or intent regarding CPR may be regarded as valid and the individual’s wishes honored.

4.2.2 An individual with a CPR Directive shall receive evaluation by EMS providers and be provided appropriate and available palliative services, treatment, and measures. 4.2.3 A valid CPR Directive constitutes lawful authority to withhold or discontinue CPR. EMS providers shall comply with an individual’s CPR Directive that is apparent and immediately available.

a) “CPR” includes, but is not limited to, artificial ventilation, chest compression, delivering electric shock, placing tubes in the airway to assist breathing, or other basic and advanced resuscitative therapies.

3 CODE OF COLORADO REGULATIONS 6 CCR 1015-2 Health Facilities and Emergency Medical Services Division b) A valid CPR Directive that has been photocopied, scanned, faxed or otherwise reproduced shall be honored.

4.2.4 In the absence of a CPR Directive, consent to CPR is presumed. 4.3 Procedure 4.3.1 In cases of cardiac or respiratory arrest or impending arrest, inquire whether the individual has an available CPR Directive.

4.3.2 When presented with a CPR Directive, obtain reasonable assurance that the individual is the person to whom it applies.

4.3.3 When presented with any valid CPR Directive, EMS providers shall not attempt to resuscitate that individual. If CPR has been initiated, it shall be discontinued. Local medical direction and prehospital protocols shall be followed. 4.3.4 Nothing in these rules shall be construed to require EMS providers to initiate CPR in the absence of a CPR Directive.

Section 5.0 - Immunity 5.1 Any EMS provider who, in good faith, complies with a CPR Directive, shall not be subject to civil or criminal liability or regulatory sanction for such compliance, pursuant to Section 15-18.6-104, C.R.S.

5.2 Any EMS provider who, in good faith, complies with a CPR directive accessed via the statewide electronic system for advance health care directives pursuant to Section 25-54-101, et seq. C.R.S., shall not be subject to civil or criminal liability or regulatory sanction for any action taken unless the EMS provider has actual knowledge of a CPR directive properly executed after the date of the advance health care directive in the electronic system, pursuant to Section 25-54- 102(3), C.R.S.

_________________________________________________________________________ Editor’s Notes History Entire rule eff. 04/30/2010.

Rules 1.2, 1.5, 1.7, 2.3, 2.11, 2.13, 3.1.1 g, 3.1.3, 3.2, 4.1.1, 4.2, 4.3.3, 4.3.4, 5.0 eff. 12/15/2019. 4