What To Do When Emergency Resuscitation Is Unwanted

JANUARY 12, 1998 VOLUME 5, NUMBER 28

In the past decade advance directives have become widespread and, at the same time, widely accepted. In fact, almost every state has adopted legislation specifically recognizing both medical powers of attorney and “living wills.” In 1992, the Arizona legislature adopted a progressive, far-reaching law on the subject.

As a result of the adoption of the 1992 law, there is no longer any doubt that both living wills and health care powers of attorney are valid in Arizona. Gone are any requirements that a person be terminally ill before such documents are valid. The law even recognizes that most people do not sign health care directives, and provides a mechanism for family members (and, in some cases, friends or other interested persons) to make most medical decisions for incapacitated patients.

Arizona law even goes one step further. It attempts to deal with one of the most difficult problems in administering advance medical directives–the response of emergency medical personnel.

Emergency medical technicians (EMTs, including paramedics) have a vital but narrow mission. They exist precisely to resuscitate patients in emergency situations, without stopping to question the patient’s history or preferences. A patient who wishes to be allowed to die peacefully is likely not to want the aggressive, sometimes even violent, treatment associated with resuscitation. In fact, some people note that the outcome of resuscitation (particularly with elderly and frail patients) is often more debilitating than the original illness or condition.

EMTs, however, correctly note that their mission is to act quickly in literal life-and-death circumstances. They do not have time to pause, ask questions of nearby family members, and review documents. They must be prepared to take decisive action in all cases.

For many years, family members of the terminally ill have been advised to avoid the problem by simply not calling on the emergency medical system. Unfortunately for that approach, the use of “911” and other emergency notification systems has become ubiquitous, and family members have a very difficult time watching even a terminally ill loved one perish without making the emergency call. Furthermore, there are many patients who are not terminally ill, but who nonetheless would not like to undergo resuscitation.

Arizona’s law tackles this problem with a separate kind of advance directive, called a Prehospital Medical Care Directive. When completed, signed and witnessed, it directs EMTs not to resuscitate even if they are called to the scene. Because it is a very potent document, and because EMTs do not have time to read individual documents, it must be in precisely the form set out by the law. It must also be on orange paper, must be signed by a medical provider (who certifies that he or she has advised the patient that lack of resuscitation could lead to death) and must include a description or picture of the patient.

The Prehospital Medical Care Directive is a unique approach to the problem of unwanted emergency resuscitation. Only one other state (Montana) has adopted a similar approach. A number of states have recently approved “Do Not Resuscitate” (DNR) orders. Unlike the DNR legislation in other states, however, the Arizona/Montana approach makes it clear that the decision is the patient’s, not the physician’s, and permits even healthy patients who fear or disapprove of emergency resuscitation to effectively make their wishes known.

Reports from EMTs indicate that the Prehospital Medical Care Directive law has worked. For a copy of the directive, or the relevant section of Arizona law, contact FLEMING & CURTI at (520) 622-0400. Remember that the directive must be on orange paper to be effective.

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