Posts Tagged ‘pre-hospital medical care directives’

Arizona’s “Orange Form” Permits Withholding Of CPR

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.

“Do Not Resuscitate” Tattoo


You may have read about Indianan Maria Rodriguez. She is the 40-year-old nurse who has had the words “No Code,” and the instructions “Pain and comfort only. Organ donor” tattooed on her stomach. In addition, her creative design includes a human heart with a circle and slash over it (the universal symbol for “no”).

While many patients might agree with Ms. Rodriguez’ sentiments, few are likely to go to the same trouble to make wishes known to paramedics and emergency room personnel. However, even if the question is purely academic we might consider whether Ms. Rodriguez has written a valid “living will” under Arizona law.

Like many states, Arizona has adopted laws recognizing several different types of “advance directives.” Most commonly, they include living wills and durable powers of attorney for health care. Ms. Rodriguez’ tattoo would not qualify as either, since it is not signed by her or properly witnessed.

Arizona also recognizes “pre-hospital medical care directives,” a category of directives intended to deal with exactly Ms. Rodriguez’ concern. By executing such a directive, a patient can direct that she would not want to be resuscitated by paramedics or emergency room personnel. These instruments, however, must be on orange paper and either letter-size or wallet-size. Ms. Rodriguez’ tattoo does not qualify.

So can nurse Rodriguez’ tattoo be dismissed as nothing more than a curiosity? No.

Even though it is not in the proper form to qualify as a formal advance directive under Arizona law, it is a potent and persuasive expression of her wishes. Since surrogate decision-makers (including agents under powers of attorney, guardians and family members) must take into consideration the wishes of the patient, the tattoo can and should be given considerable weight in gauging Ms. Rodriguez’ desires. Ms. Rodriguez has taken an original and effective step toward ensuring that her wishes are honored. Few providers will forget her wishes.

White House Conference on Aging

For the past five weeks, Elder Law Issues has described the topics focused on by Arizona’s Conference on Aging held in January. That conference was Arizonans’ chance to help shape the agenda for the full White House Conference on Aging.

The national Conference will be held in Washington, D.C., the first week of May, 1995. Within the next few weeks, we will tell you more about the Arizona conference’s recommendations and conclusions.

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