Good day,
I hope this finds you well. My name is Tyler Letren and I believe the United States should establish a federal Do Not Resuscitate and advance directive database that can be accessed rapidly by authorized medical personnel using verified patient identifiers such as personal information, fingerprints, dental records, or DNA where appropriate and legally permitted.
A system of this kind would help ensure that a patient’s documented wishes are available in real time, regardless of where they are receiving care. It would give hospitals, emergency rooms, and medical teams across the country, including Alaska, Hawaii, and U.S. territories, the ability to confirm DNR status quickly and act in accordance with the patient’s directive.
Best,
Tyler Letren, CEO of MVTT BLVC
To establish the National Advance Directive Registry System (ADRS), a federally maintained, rapidly accessible database of Do-Not-Resuscitate orders, POLST forms, and advance healthcare directives, accessible in real time to all licensed medical personnel throughout the United States, its territories, and possessions.
Preamble
WHEREAS, the right of individuals to direct their own medical care, including end-of-life decisions, is a fundamental constitutional and human right;
WHEREAS, Do-Not-Resuscitate orders, POLST forms, and advance healthcare directives are currently maintained in fragmented, incompatible, and jurisdiction-specific systems that create life-threatening gaps in care;
WHEREAS, out-of-hospital DNR orders governing EMS and in-hospital DNR orders are legally and procedurally distinct instruments requiring separate operational frameworks within any national registry;
WHEREAS, emergency query response times of 60 seconds or less, and offline functionality for low-connectivity environments, are clinical necessities, not aspirational goals;
WHEREAS, biometric identification methods vary significantly in clinical applicability: fingerprint scanning is viable in real-time emergency care for living patients, while DNA analysis and dental record comparison are forensic processes taking days to weeks and are appropriate only for post-mortem identification or mass casualty incident management;
WHEREAS, healthcare providers acting in good faith on registry records must be afforded clear statutory liability protection to ensure clinical adoption;
NOW, THEREFORE, be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled:
Short Title
This Act may be cited as the "National Advance Directive Registry System Act of 2026" or the "ADRS Act of 2026."
Findings and Purpose
(a) Congressional Findings
- Advance directives, POLST forms, and DNR orders are legally valid physician-endorsed documents. A DNR order is a medical order requiring physician co-signature; it is not solely a patient-authored document.
- No unified national system currently exists for storing, indexing, or retrieving these documents across state lines, territories, or during emergency transport.
- Current state-level registries are incompatible with one another, and many EMS agencies, rural hospitals, and critical access facilities in Alaska, Hawaii, and U.S. territories operate without any reliable directive lookup system.
- Fingerprint biometrics are clinically viable for real-time patient identification in emergency settings. DNA profiling and dental record comparison require forensic laboratory processing and are appropriate only for post-mortem identification or mass casualty victim management — not acute emergency care.
- Patients retain the absolute right to revoke any advance directive at any time, including through non-verbal means. No registry record shall override a patient's contemporaneous expressed wishes.
- Healthcare providers require statutory safe harbor protection when acting in good faith on registry records to encourage clinical adoption without fear of civil liability.
(b) Purpose
- Establish the ADRS as a secure, federally administered, real-time medical record system;
- Integrate DNR orders (out-of-hospital and in-hospital), POLST forms, living wills, and healthcare proxy designations;
- Ensure emergency query response times of 60 seconds or less and offline functionality for low-connectivity environments;
- Authorize clinically appropriate patient identification methods stratified by emergency context;
- Establish clear liability protections for providers acting in good faith on registry records;
- Protect individual privacy and civil liberties through strict access controls, audit trails, and data security standards.
Definitions
(1) ADVANCE DIRECTIVE. Any legally valid document by which a competent individual expresses instructions regarding their medical care, including DNR orders, living wills, POLST forms, and healthcare proxy designations.
(2) DNR ORDER (DO-NOT-RESUSCITATE). A physician medical order instructing healthcare providers not to perform CPR. Distinguished as: (A) IN-HOSPITAL DNR — valid within an inpatient facility and entered in the patient's medical record; and (B) OUT-OF-HOSPITAL DNR (OOH-DNR) — a portable physician order, in many states requiring a specific state-issued form, instructing EMS and other pre-hospital providers not to initiate resuscitative measures.
(3) POLST. Physician Orders for Life-Sustaining Treatment. A standardized, portable medical order set signed by both the patient (or surrogate) and a licensed clinician, specifying wishes regarding resuscitation, medical interventions, and artificial nutrition. POLST forms carry immediate clinical authority and are distinct from living wills or general advance directives.
(4) DECISION-MAKING CAPACITY. The clinical determination, made by a licensed healthcare provider, that a patient is able to understand relevant information, appreciate consequences, reason about options, and communicate a consistent choice. Advance directives and DNR orders activate only upon documented loss of decision-making capacity, unless otherwise specified in the order.
(5) AUTHORIZED MEDICAL PERSONNEL. Licensed physicians, registered nurses, licensed practical nurses, EMTs, paramedics, physician assistants, nurse practitioners, respiratory therapists, hospice staff, and any other licensed healthcare provider acting within their scope of practice under applicable state law.
(6) EMERGENCY QUERY. A query to the ADRS initiated during an active medical emergency where treatment decisions must be made within minutes.
(7) REGISTRY RECORD. The complete patient file within the ADRS, including all uploaded advance directive documents, physician co-signature verification, registration history, and audit log.
(8) SECRETARY. The Secretary of Health and Human Services.
(9) TERRITORIES AND POSSESSIONS. Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, the Commonwealth of the Northern Mariana Islands, and any other territory or possession of the United States.
Establishment of the National Advance Directive Registry System
(a) In General
Not later than 3 years after the date of enactment of this Act, the Secretary, in consultation with the Centers for Medicare & Medicaid Services, the National Association of EMS Physicians, the American Medical Association, the American Nurses Association, and the heads of relevant federal agencies, shall establish and maintain the National Advance Directive Registry System (ADRS).
(b) Document Types Indexed
- Out-of-Hospital DNR orders (OOH-DNR), including all state-specific standardized forms;
- In-Hospital DNR orders, integrated via EHR interfaces;
- POLST and MOLST (Medical Orders for Life-Sustaining Treatment) forms;
- Living wills and general advance healthcare directives;
- Healthcare proxy, durable power of attorney for healthcare, and surrogate designations;
- Organ and tissue donation authorizations.
(c) Performance Standards
- Emergency query response time: All emergency queries shall return a result or confirmed no-record response within 60 seconds under standard network conditions.
- System availability: The ADRS shall maintain 99.9% uptime with redundant failover infrastructure.
- Offline functionality: The ADRS mobile and EMS terminal application shall support a locally cached, encrypted copy of records for patients who consent to pre-registration of offline access, updated at minimum every 24 hours, for use in areas with no network connectivity.
- EHR interoperability: The ADRS shall publish and maintain HL7 FHIR-compliant APIs for bidirectional integration with certified EHR systems (Epic, Cerner, Oracle Health, and equivalents) within 2 years of system launch.
(d) Geographic Coverage
The ADRS shall be fully operational and accessible across all 50 states, the District of Columbia, all U.S. territories and possessions, and U.S. military installations and VA medical facilities. The Secretary shall establish dedicated infrastructure nodes in Alaska and Hawaii to address latency challenges, and shall provide satellite-linked access solutions for remote and rural areas lacking broadband connectivity.
Patient Identification Methods — Stratified by Clinical Context
The following identification methods are authorized for ADRS queries, stratified by clinical context to reflect real-world medical applicability:
| Identification Method | Clinical Context | Applicability | Access Tier |
|---|---|---|---|
| Name + Date of Birth | All contexts | Primary method — fastest lookup | All authorized personnel |
| Gov't ID / SSN (last 4) | All contexts | Standard secondary method | All authorized personnel |
| Medicare / Medicaid ID | Inpatient / insured | Useful when insurance card present | All authorized personnel |
| QR Code / NFC Medical ID Tag | Pre-registered patients | Fastest method for opt-in patients; scannable by standard EMS device; <10 sec return | All authorized personnel |
| Fingerprint Scan | Living patients — incapacitated or unidentified | Real-time viable; requires HHS-certified scanner at facility or EMS unit | Certified facilities and EMS agencies only |
| DNA Profile Forensic Only | Post-mortem / mass casualty ONLY | Requires lab processing (days to weeks). NOT for acute emergency care. | Forensic medical examiner / FBI CODIS — restricted access |
| Dental Records Forensic Only | Post-mortem / mass casualty ONLY | Requires forensic odontologist comparison. NOT for acute emergency care. | Forensic medical examiner only |
(b) QR Code / NFC Medical ID Opt-In Program
The Secretary shall establish a voluntary opt-in program under which registered patients may receive a wallet card, wristband, or medical alert device bearing a QR code or NFC chip linked directly to their ADRS record. Upon scanning by any authorized medical personnel using an ADRS-enabled device, the patient's current directive status shall be returned within 10 seconds. Participation shall be at no cost to the patient.
(c) Biometric Data Use Restrictions
Fingerprint data shall be used solely for patient identification and directive retrieval. Such data shall not be shared with law enforcement, immigration authorities, or any non-medical entity except pursuant to a valid court order. All biometric data shall be encrypted at AES-256 standard and subject to annual independent security audits.
Clinical Activation, Revocation, and Conflict Resolution
(a) Activation Threshold
A DNR order or advance directive retrieved from the ADRS shall be clinically active and binding upon all of the following conditions being met:
- The attending clinician or EMS provider has determined, based on available clinical information, that the patient lacks current decision-making capacity; AND
- The retrieved registry record bears a verified physician co-signature or is a valid POLST form with clinician endorsement; AND
- The patient has not presented a contemporaneous verbal or non-verbal revocation as described in subsection (b).
(b) Revocation — Patient Rights
Any individual registered in the ADRS retains the absolute and unconditional right to revoke their advance directive at any time. Revocation shall be recognized in the following forms:
- Written revocation submitted to the ADRS portal, effective immediately upon submission;
- Verbal revocation communicated directly to any authorized medical personnel, documented in the patient's medical record and flagged in the ADRS within 24 hours;
- Any clearly intentional non-verbal action by a patient who retains decision-making capacity indicating a desire to receive treatment shall be treated as contemporaneous revocation and shall take precedence over any registry record.
(c) Family or Surrogate Conflict Protocol
- The attending physician retains final clinical authority in the immediate emergency context, weighing the registry record, documented patient wishes, family input, and current clinical status;
- In non-emergent or transitional care settings, hospital ethics consultation shall be offered;
- The ADRS shall not be cited as the sole determinative basis for clinical decisions in contested cases; it is an evidentiary tool, not an automatic order execution system;
- Where a surrogate holding valid durable power of attorney for healthcare presents documentation contradicting the registry record, the provider shall document both and exercise independent clinical judgment until legal clarity is obtained.
(d) Document Currency and Expiration
The ADRS shall display the date of most recent update for every registry record. The Secretary shall establish guidelines recommending that POLST forms and DNR orders be reviewed and reconfirmed at minimum every 12 months for patients with progressive or terminal diagnoses. The ADRS shall send automated renewal reminders to the registered patient and their designated clinician.
Provider Liability Protections
(a) Good Faith Safe Harbor
A healthcare provider — including physicians, nurses, EMTs, paramedics, and all authorized medical personnel — who acts in good faith in accordance with an advance directive or DNR order retrieved from the ADRS shall not be subject to civil or criminal liability for actions taken in reasonable reliance on such record, provided that:
- The provider made a reasonable attempt to query the ADRS or confirm the record's currency;
- The provider documented the registry query and the record returned in the patient's medical record;
- The provider did not have actual knowledge that the record was invalid, revoked, or fraudulently entered.
(b) No Liability for Technical Failures
No authorized medical personnel shall be held liable for clinical decisions made when the ADRS was unavailable due to system outage, network failure, or connectivity limitations, provided the provider acted in accordance with applicable clinical standards of care and facility protocol.
(c) Institutional Protections
Healthcare institutions and EMS agencies that adopt and implement ADRS access protocols in accordance with this Act shall be presumed to have met their institutional duty of care with respect to advance directive verification.
Voluntary Registration and Patient Rights
(a) Voluntary Participation
Registration in the ADRS shall be entirely voluntary. No individual shall be required to register as a condition of receiving medical care, insurance coverage, or government benefits.
(b) Individual Rights
- Access their own registry record at any time, at no cost, through a secure patient portal;
- Amend, update, or revoke their advance directive registration at any time, effective immediately;
- Receive a complete audit log of all ADRS queries made regarding their record;
- Request permanent deletion from the registry, effective within 30 days;
- Designate a legal representative or healthcare proxy authorized to manage their registry record;
- Opt in or out of the QR code / NFC Medical ID program at any time.
(c) Registration Pathways
- A licensed physician who co-signs and electronically files the directive;
- A hospital, hospice, skilled nursing facility, or long-term care facility at the time of admission;
- A state-certified advance directive registry participating in the ADRS interoperability framework;
- Direct submission via the ADRS secure online patient portal, subject to physician co-signature requirement for POLST and DNR instruments.
Privacy Protections and Data Security
(a) HIPAA Compliance
The ADRS shall operate in full compliance with HIPAA (Public Law 104-191) and all implementing regulations under 45 C.F.R. Parts 160 and 164.
(b) Access Controls
- Authorized medical personnel acting in their licensed capacity;
- The registered individual through secure two-factor patient portal authentication;
- Legally designated healthcare proxies or durable power of attorney holders;
- HHS administrative personnel for system maintenance under strict data isolation protocols.
(c) Data Segregation
Biometric data (fingerprint templates) shall be stored in a physically and logically segregated database from medical directive content. The biometric store shall be used solely to return a patient identifier and shall not contain clinical information.
(d) Audit Logging and Transparency
Every query made to the ADRS shall be automatically logged with the date, time, querying personnel credentials, facility, query method, and the record accessed. Audit logs shall be retained for a minimum of 7 years and shall be available to patients upon request at no cost.
(e) Penalties for Unauthorized Access
- Civil penalties of not less than $50,000 and not more than $250,000 per violation;
- Criminal penalties of up to 10 years imprisonment for willful misuse;
- Permanent revocation of ADRS access credentials and mandatory referral to the applicable state medical licensing board.
Interoperability and State Coordination
The Secretary shall develop a federal interoperability framework enabling all states, the District of Columbia, and all U.S. territories to integrate their existing advance directive registries with the ADRS within 5 years of enactment. States shall not be required to dismantle existing systems but shall be incentivized through federal grants to achieve bidirectional FHIR-compliant data-sharing. The Secretary shall publish a minimum data standard for state registry interoperability within 18 months of enactment, and shall work with POLST paradigm organizations and national EMS medical director associations to harmonize state-specific OOH-DNR form requirements with ADRS intake standards.
Bipartisan Oversight Board
There is hereby established the National ADRS Oversight Board, comprising:
- 4 Senate majority appointments & 4 Senate minority appointments;
- 4 House majority appointments & 4 House minority appointments;
- 2 representatives from the AMA and ANA;
- 2 representatives from the National Association of EMS Physicians (NAEMSP) and National EMS Medical Directors;
- 2 patient rights and privacy advocacy representatives;
- 1 representative from each U.S. territory covered by this Act.
The Board shall submit annual public reports to Congress on ADRS performance, access equity, clinical adoption rates, security incidents, and recommended improvements.
Authorization of Appropriations
| Fiscal Year | Amount | Purpose |
|---|---|---|
| FY 2027 | $750,000,000 | Initial system design, infrastructure, EHR integration development, and state grant program establishment |
| FY 2028 – 2030 | $350,000,000 / year | System deployment, state registry integration, QR/NFC Medical ID program, and EMS terminal rollout |
| FY 2031 and thereafter | $150,000,000 / year | Ongoing maintenance, security audits, and operations |
Severability
If any provision of this Act, or the application thereof to any person or circumstance, is held invalid, the remainder of this Act and the application of such provision to other persons or circumstances shall not be affected thereby.
Sponsors
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— End of Bill —
Clinically revised draft prepared for bipartisan legislative review. Not for public distribution.