DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Health Facilities and Emergency Medical Services Division RULES PERTAINING TO THE IMPLEMENTATION OF CARDIOPULMONARY RESUSCITATION (CPR) DIRECTIVES BY EMERGENCY MEDICAL SERVICE PERSONNEL 6 CCR 1015-2 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] _________________________________________________________________________ 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 personnel.

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 personnel 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 personnel. 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 selected pursuant to Section 15-18.5-103, C.R.S.

2.4 “Board” means the State Board of Health created pursuant to Section 25-1-103, C.R.S. Code of Colorado Regulations 1

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) Personnel” means any emergency medical technician at any level who is certified or licensed by the Department of Public Health and Environment. “EMS Personnel” also includes a first responder certified by the Department of Public Safety, in accordance with Section 24-33.5-1203, C.R.S.

2.12 “Individual” means the person who is the subject of a CPR Directive.

2.13 “Palliative” refers to measures and treatments intended for relief of pain and suffering including, but not limited to, medication by any route, positioning, oxygen, suction, and manual treatment of airway obstruction as needed for comfort.

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

1. 3.1.1 A CPR Directive, executed pursuant to these rules, shall contain the following information:
   1. a) name, date of birth, sex, eye and hair color, and race or ethnic background;
   2. b) if applicable, the name of the hospice program in which the individual is enrolled;
   3. c) the directive concerning the administration of CPR to the individual;
   4. d) the signature or mark of the individual or authorized agent;
   5. e) the date on which the CPR Directive was signed by the individual or authorized agent;
   6. 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 12-34-101, C.R.S., et seq., then in effect.

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1. 3.1.2 A CPR Directive may be made in any other manner.
   1. a) A CPR Directive bracelet or necklace may be regarded as valid.
2. 3.1.3 Any CPR Directive that is apparent and immediately available to EMS personnel and which directs that resuscitation not be attempted constitutes lawful authority to withhold or discontinue CPR.

3.2 Revocation of a CPR Directive

1. 3.2.1 A CPR Directive may be revoked at any time by the individual who is the subject of such directive or by the authorized agent for that individual. 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.

Section 4 - General Protocol for Implementation of CPR Directives

4.1 Purpose

1. 4.1.1 To provide guidance for the implementation of CPR Directives by EMS personnel. 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.
   1. 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.
   2. 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.
2. 4.2.2 An individual with a CPR Directive shall receive evaluation by EMS personnel and be provided appropriate and available palliative treatment and measures.
3. 4.2.3 A CPR Directive may be revoked at any time by the individual who is the subject of such directive or by the authorized agent for that individual. 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. Family or bystanders who are not the declarant may not revoke a CPR Directive.
4. 4.2.4 A valid CPR Directive constitutes lawful authority to withhold or discontinue CPR. EMS personnel shall comply with an individual’s CPR Directive that is apparent and immediately available.
   1. 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.
   2. b) A valid CPR Directive that has been photocopied, scanned, faxed or otherwise reproduced shall be honored.
5. 4.2.5 In the absence of a CPR Directive, consent to CPR is presumed.

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4.3 Procedure

1. 4.3.1 In cases of cardiac or respiratory arrest or impending arrest, inquire whether the individual has an available CPR Directive.
2. 4.3.2 When presented with a CPR Directive, obtain reasonable assurance that the individual is the person to whom it applies.
3. 4.3.3 When presented with any valid CPR Directive, EMS personnel 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. 4.3.4 Nothing in these rules shall be construed to require EMS personnel to initiate CPR in the absence of a CPR Directive.

Section 5.0 - Immunity 5.1 Any EMS personnel, 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.

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

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