JUNE 5, 2000 VOLUME 7, NUMBER 49
Living wills and health care powers of attorney may take care of most of the end-of-life medical decisions you (or a loved one) will face. But for many patients the final medical decisions must be made outside of the hospital setting. Rather than doctors and nurses, the treatment team may consist entirely of paramedics (or emergency medical technicians—"EMTs").
EMTs are well-trained, and save thousands of lives every year. The United States is lucky to have an extensive system for emergency care outside the hospital; in most medical emergencies in this country, the wait for an EMT will be a matter of minutes. But EMTs are not doctors, and do not have the luxury of time for thoughtful consideration of the medical history and wishes of the patient or family.
In practice that can translate into a very real dilemma. The terminally ill patient who wishes to avoid resuscitation efforts may have a difficult time ensuring that death can come peacefully. If an emergency call is made (to 911, for example), EMTs may be forced to attempt resuscitation and to transport the patient to the nearest hospital.
As a result of that dilemma, most states have adopted some formalized version of the physicians’ "Do Not Resuscitate" instruction (usually referred to as a "DNR" order). As of late 1999, all but seven of the states (Delaware, Iowa, Mississippi, Nebraska, North Dakota, Pennsylvania and Vermont) had state laws or administrative orders permitting non-hospital DNR orders in at least some specified circumstances.
Some states have developed forms for DNR orders, like the Physician’s Order on Life Sustaining Treatment (the "POLST" form) in Oregon, which are widely recognized and used. Massachusetts, as another example, has recently instructed EMTs to resuscitate patients unless they are presented with a "Comfort Care/DNR Order Verification Protocol Form." In both of these examples, the form sanctioned by the government and utilized by EMTs is based on the physician’s instruction.
As usual, Arizona has taken a different approach. Rather than leaving the matter to the attending physician, Arizona law permits the individual to sign his or her own instruction to withhold resuscitation. The "Pre-hospital Medical Care Directive" must be in the precise form authorized by law, and must be on orange paper. Because of the color requirement it is commonly referred to as the "orange form." Once a patient or health care agent has signed the form, EMTs are allowed to forego resuscitation. Arizona's law on pre-hospital medical care directives can be found at Arizona Revised Statutes section 36-3251.
An important word of caution—most patients who are not terminally ill probably will not want to direct that resuscitation not be attempted. If you are in Arizona and wish to sign the "orange form" contact Fleming & Curti, P.L.C., and we will be happy to provide one at no charge.