1.0 Purpose and Authority

1.1 Title 15, Article 18.6 of the Colorado Revised Statutes, directs the Colorado Board of Health to promulgate rules and protocols for implementation of CPR Directives by emergency medical service personnel. C.R.S. 15-18.6-103 states that protocols must include uniform methods for identifying persons who have executed a CPR Directive, and controlled methods for distributing CPR Directives. A CPR Directive which is apparent and immediately available to emergency medical service personnel, and which directs that CPR not be administered, constitutes lawful authority to withhold CPR. In the absence of a CPR Directive, consent to CPR is presumed.

1.2 Specific statutory authority is found in C.R.S. 15-18.6-103.

2.0 Definitions

2.1 “Attending Physician” means a licensed Medical Doctor (M.D.) or licensed Doctor of Osteopathy (D.O.) that the declarant has consulted for execution of a CPR Directive.

2.2 “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 3.1(b) of these rules. “Authorized Agent” includes a proxy selected pursuant to C.R.S. 15-18.5-103.

2.3 “Board” means the Colorado Board of Health.

2.4 “Cardiac Arrest” means the cessation of a functional heartbeat.

2.5 “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, chest compression, delivering electric shock to the chest, or placing tubes in the airway to assist breathing.

2.7 “Declarant” means a person who has executed a CPR Directive. The declarant may be the person named within the directive or, the authorized agent of a person for whom the directive applies.

2.8 “Department” means the Colorado Department of Public Health and Environment.

2.9 “Emergency Medical Service Personnel” means any emergency medical technician at any level who is certified or licensed by the Department of Public Health and Environment. “Emergency Medical Service Personnel” includes a first responder certified by the Department of Public Health and Environment or the Division of Fire safety, Department of Public Safety, in accordance with C.R.S. 24-33.5-1205(2)(c).

2.10 “On Line Medical Control” means physician-directed communications that routinely provide professional medical support through radio or telephonic communications to emergency medical service personnel.

2.11 “Prehospital Care Report” means a standard report completed by emergency medical service personnel for the purpose of documenting information concerning patient identity, patient condition, medical history, treatment, and transportation.

2.12 “Respiratory Arrest” (Pulmonary Arrest) means cessation of functional breathing.

2.13 “Resuscitation” means performing CPR.

3.0 General Provisions for CPR Directives

3.1 Persons Eligible to Execute a CPR Directive.

a) Any adult over the age of eighteen who has the decisional capacity to provide informed consent to or refusal of medical treatment or an authorized agent acting for an adult who lacks such decisional capacity, may execute a CPR Directive.

b) After a physician has issued a Do Not Resuscitate Order for a minor child, a CPR Directive may be executed for the minor by the minor's parents, if married and living together, the custodial parent, or the legal guradian.

3.2 CPR Directive Form

The CPR Directive form shall be a unique document printed on distinctive security, as approved by the Board, and consistent with these rules. The following requirements and provisions shall apply to the approved CPR Directive. The form shall contain:

1. a) name, date of birth, sex, eye and hair color, and race or ethnic background of the person for whom the CPR Directive applies;
2. b) if applicable, the name of the hospice program in which the person for whom the CPR Directive applies is enrolled;
3. c) a statement indicating that the declarant has been informed of the expected consequences of withholding CPR;
4. d) the declarant's directive concerning the administration of CPR;
5. e) signature or mark of the declarant;
6. f) the date on which the CPR Directive was signed by the declarant;
7. g) the attending physician's name, address, telephone number, and signature; and h) a written statement and signature indicating a decision regarding tissue donation upon a patient's death.

3.3 CPR Directive Bracelet or Necklace

A CPR Directive bracelet or necklace, as approved by the Department, may be ordered after the CPR Directive has been executed as provided in 4.1(b). Wearing the bracelet or necklace is strongly encouraged but not mandatory. Such bracelet or necklace shall be a unique, and easily recognizable identification bracelet or necklace containing the person's name, date of birth, sex, and race.

3.4 Authenticity for compliance with CPR Directive

For persons who have executed a CPR Directive pursuant to these rules, only an unaltered CPR Directive with original signatures by the declarant and the physician, or an unaltered CPR Directive bracelet or necklace shall be valid for the purpose of withholding or withdrawing CPR by emergency medical service personnel in the event of cardiac arrest or respiratory arrest.

3.5 Revocation of CPR Directive

A CPR Directive may be revoked at any time by:

1. a) physical cancellation or destruction of the CPR Directive and bracelet or necklace if used, by the declarant or another person acting at the declarant's direction; or b) oral expression of revocation by the declarant.
2. c) A guardian, agent or proxy decision-maker may revoke a CPR Directive in the same manner as provided in this section only if a guardian, agent or proxy-decision maker originally executed the CPR Directive.

3.6 Distribution of CPR Directive Forms

The department or a designated agency, association, or institution which has entered into agreement with the department and has been approved by the Board shall make CPR Directive forms available to attending physicians, home health agencies or licensed or certified health care facilities as defined in 15-14-505 C.R.S.

4.0 General Protocols for Implementation of the CPR Directive

4.1 Attending Physician Responsibilities

a) An attending physician who is assisting a declarant shall ensure that the declarant:

1. 1) receives an explanation of the expected consequences of withholding or withdrawing CPR;
2. 2) is informed that if the CPR Directive or bracelet or necklace is not apparent and immediately available, or has been altered, CPR will be initiated by emergency medical service personnel;
3. 3) receives an explanation of how and by whom the CPR Directive may be revoked; and 4) signs the CPR Directive.

b) The attending physician shall execute the CPR Directive by signing and dating the form after a signature is obtained from the declarant.

c) The attending physician may assist the declarant in determining the appropriate person(s) or agencies to be contacted in the event of an anticipated death.

4.2 Declarant Responsibilities

The declarant is responsible for making informed decisions concerning the refusal of resuscitative procedures in the event of a cardiac or respiratory arrest, signing the original form, affixing the bracelet or necklace, if it is to be worn, and informing family members and care givers of the CPR Directive and its location. The declarant is encouraged to notify the local EMS provider agency of the CPR Directive, and inform family members and care givers whom to contact in the event of an anticipated death.

4.3 Family and Care Giver Responsibilities

The family and care giver, as applicable, should be aware of the CPR Directive location and whom to contact in the event of an anticipated death. They should also be aware of the expected prehospital response should they activate an emergency 9-1-1 call and realize their responsibility to abide by the declarant's CPR Directive.

4.4 Emergency Medical Service Personnel Responsibilities

Emergency medical service personnel shall comply with the following general procedures when responding to a patient who is in cardiac or respiratory arrest.

a) Patient Assessment and Intervention.

1. Emergency medical service personnel shall perform patient assessment and intervention. If an unaltered CPR Directive or bracelet or necklace is found during assessment, emergency medical service personnel shall obtain reasonable assurance that the patient is the person for whom the CPR Directive or bracelet or necklace applies.

b) Resuscitative Measures to be Withheld or Withdrawn In the event of cardiac or respiratory arrest of a patient with a valid CPR Directive or bracelet or necklace, the following procedures shall be withheld or withdrawn by qualified emergency medical service personnel:

1. 1) CPR;
   1. 2) endotracheal intubation or other advanced airway management;
   2. 3) artificial ventilation;
   3. 4) defibrillation;
   4. 5) cardiac resuscitation medications; and 6) related procedures, as defined by attending physician, medical protocols, or on-line medical control.

c) Procedures to Provide Comfort Care or Alleviate Pain The following interventions may be provided as appropriate to a patient with a valid CPR Directive or bracelet or necklace, and are dependent upon the needs of the particular patient:

1. 1) assist in maintenance of an open airway, excluding intubation or advanced airway management;
   1. 2) provide suction;
   2. 3) provide oxygen;
   3. 4) provide pain medications;
   4. 5) control bleeding;
   5. 6) provide comfort care; and 7) be supportive to patient and family.

d) Action Required if Directive is Revoked If a CPR Directive is revoked, EMS personnel shall perform full resuscitation and treatment of the patient.

e) Documentation When encountering a CPR Directive or bracelet or necklace for a particular patient, emergency medical service personnel shall document the response in the following way:

1. 1) Using the agency prehospital care report form, the following information must be included:
   1. a. description of patient's status;
      1. b. documentation of which identification (form or bracelet or necklace) was used to confirm CPR Directive status;
      2. c. recording of the name of the patient's attending physician;
      3. d. any variations in procedures which contradict the honoring of a CPR Directive.

f) General Considerations The following general principles shall apply to a CPR Directive.

1. 1) A patient with a CPR Directive shall be provided appropriate comfort care and treatment by emergency medical service, personnel.
   1. 2) An original CPR Directive or the bracelet or necklace shall be apparent and immediately available. If there is a misunderstanding with family members or others at the scene, or other questions concerning the CPR Directive or bracelet or necklace, emergency medical service personnel may utilize on-line medical control for guidance.
   2. 3) If there is reasonable question about the validity of a CPR Directive or bracelet or necklace, or the identity of the patient, resuscitation shall be initiated.
   3. 4) If patient is transported, keep the CPR Directive or bracelet or necklace with the patient.

5.0 Other advance directives pertaining to CPR

Nothing in these rules shall be construed to restrict any other manner in which a person may make an advance medical directive pertaining to the administration of CPR.