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Links:
Death To Dust: What Happens To Dead Bodies? Death To Dust: What Happens To Dead Bodies?
Grave Words: Notifying Survivors About Unexpected Deaths Grave Words: Notifying Survivors About Unexpected Deaths
Ethics In Emergency Medicine Ethics In Emergency Medicine

Sample Advance Directives:

· Durable Power of Attorney for Health Care (Health Care Power of Attorney)
· Living Will
· Prehospital Advance Directive

Arizona has perhaps the most modern advance directive law in the country. Simple and designed for people to download and use, Arizonans have successfully used these documents for about a decade. There are several unique things about these documents.

  1. There is no requirement for patients to be "terminal" (whatever that means) to use them.
  2. They can be used for children (such as those in home hospice programs) as well as adults.
  3. They are ADVANCE DIRECTIVES, not physician orders. Patients initiate them.
  4. The prehospital advance directive law ("orange form") has eliminated the unwanted and often accidental resuscitative efforts in dying patients. Few other states have such a patient-friendly device. [For additional information about this form, see: Iserson KV: A simplified prehospital advance directive law: Arizona's approach. Ann Emerg Med 1993;22:11:1703-1710.]

Show these to your legislators! There is no reason why your state can't have such simple, usable, patient-friendly forms.

ARS. 36-3224. SAMPLE HEALTH CARE POWER OF ATTORNEY

Any writing that meets the requirements of section 36-3221 may be used to create a health care power of attorney. The following form is offered as a sample only and does not prevent a person from using other language or another form:

1. Health Care Power of Attorney

I, __________________________, as principal, designate _________________ as my agent for all matters relating to my health care, including, without limitation, full power to give or refuse consent to all medical, surgical, hospital and related health care. This power of attorney is effective on my inability to make or communicate health care decisions. All of my agent's actions under this power during any period when I am unable to make or communicate health care decisions or when there is uncertainty whether I am dead or alive have the same effect on my heirs, devisees and personal representatives as if I were alive, competent and acting for myself.
If my agent is unwilling or unable to serve or continue to serve, I hereby appoint ____________________ as my agent.
I have _____ I have not _____ completed and attached a living will for purposes of providing specific direction to my agent in situations that may occur during any period when I am unable to make or communicate health care decisions or after my death. My agent is directed to implement those choices I have initialed in the living will.
I have _____ I have not _____ completed a prehospital medical care directive pursuant to section 36-3251, Arizona Revised Statutes.
This health care directive is made under section 36-3221, Arizona Revised Statutes, and continues in effect for all who may rely on it except those to whom I have given notice of its revocation.
___________________________
Signature of Principal
Witness: ________________ Date: ____________________
__________________________ Time: ____________________

Address: ________________ ___________________________ __________________________ Address of Agent
Witness: ________________ ___________________________
__________________________ Telephone of Agent

Address: ________________
__________________________
(Note: This document may be notarized instead of being witnessed.)
2. Autopsy (under Arizona law an autopsy may be required)
If you wish to do so, reflect your desires below:

_______ 1. I do not consent to an autopsy.

_______ 2. I consent to an autopsy.

_______ 3. My agent may give consent to or refuse an autopsy.

3. Organ Donation (Optional)

(Under Arizona law, you may make a gift of all or part of your body to a bank or storage facility or a hospital, physician or medical or dental school for transplantation, therapy, medical or dental evaluation or research or for the advancement of medical or dental science. You may also authorize your agent to do so or a member of your family may make a gift unless you give them notice that you do not want a gift made. In the space below you may make a gift yourself or state that you do not want to make a gift. If you do not complete this section, your agent will have the authority to make a gift of a part of your body pursuant to law. Note: The donation elections you make in this health care power of attorney survive your death.)
If any of the statements below reflects your desire, initial on the line next to that statement. You do not have to initial any of the statements.
If you do not check any of the statements, your agent and your family will have the authority to make a gift of all or part of your body under Arizona law.
_______ I do not want to make an organ or tissue donation and I do not want my agent or family to do so.
_______ I have already signed a written agreement or donor card regarding organ and tissue donation with the following individual or institution: _____________________________
_______ Pursuant to Arizona law, I hereby give, effective on my death:
[] Any needed organ or parts.
[] The following part or organs listed:
____________________________________
____________________________________
____________________________________
for (check one):
[] Any legally authorized purpose.
[] Transplant or therapeutic purposes only.

4. Physician Affidavit (optional)

(Before initialing any choices above you may wish to ask questions of your physician regarding a particular treatment alternative. If you do speak with your physician it is a good idea to ask your physician to complete this affidavit and keep a copy for his file.)
I, Dr. ________________________ have reviewed this guidance document and have discussed with _________ any questions regarding the probable medical consequences of the treatment choices provided above. This discussion with the principal occurred on ________________.
(date)
I have agreed to comply with the provisions of this directive.
___________________________
Signature of Physician
5. Living Will (Optional. Section 36-3262, Arizona Revised Statutes, has a sample living will.)

ARS 36-3262. SAMPLE LIVING WILL
Any writing that meets the requirements of this article may be used to create a living will. A person may write and use a living will without writing a health care power of attorney or may attach a living will to the person's health care power of attorney. If a person has a health care power of attorney, the agent must make health care decisions that are consistent with the person's known desires and that are medically reasonable and appropriate. A person can, but is not required to, state the person's desires in a living will. The following form is offered as a sample only and does not prevent a person from using other language or another form:

Living Will

(Some general statements concerning your health care options are outlined below. If you agree with one of the statements, you should initial that statement. Read all of these statements carefully before you initial your selection. You can also write your own statement concerning life-sustaining treatment and other matters relating to your health care. You may initial any combination of paragraphs 1, 2, 3 and 4 but if you initial paragraph 5 the others should not be initialed.)

_____ 1. If I have a terminal condition I do not want my life to be prolonged and I do not want life-sustaining treatment, beyond comfort care, that would serve only to artificially delay the moment of my death.

_____ 2. If I am in a terminal condition or an irreversible coma or a persistent vegetative state that my doctors reasonably feel to be irreversible or incurable, I do want the medical treatment necessary to provide care that would keep me comfortable, but I do not want the following:

_____ (a) Cardiopulmonary resuscitation, for example, the use of drugs, electric shock and artificial breathing.

_____ (b) Artificially administered food and fluids.

_____ (c) To be taken to a hospital if at all avoidable.

_____ 3. Notwithstanding my other directions, if I am known to be pregnant, I do not want life-sustaining treatment withheld or withdrawn if it is possible that the embryo/fetus will develop to the point of live birth with the continued application of life-sustaining treatment.

_____ 4. Notwithstanding my other directions I do want the use of all medical care necessary to treat my condition until my doctors reasonably conclude that my condition is terminal or is irreversible and incurable or I am in a persistent vegetative state.

_____ 5. I want my life to be prolonged to the greatest extent possible.

Other or Additional Statements of Desires

I have _____ I have not _____ attached additional special provisions or limitations to this document to be honored in the absence of my being able to give health care directions.

ARS: 36-3251. PREHOSPITAL MEDICAL CARE DIRECTIVES; FORM; EFFECT; DEFINITION

A. Notwithstanding any law or a health care directive to the contrary, a person may execute a prehospital medical care directive that, in the event of cardiac or respiratory arrest, directs the withholding of cardiopulmonary resuscitation by emergency medical system and hospital emergency department personnel. For the purposes of this article, "cardiopulmonary resuscitation" shall include cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, administration of advanced cardiac life support drugs and related emergency medical procedures. Authorization for the withholding of cardiopulmonary resuscitation does not include the withholding of other medical interventions, such as intravenous fluids, oxygen or other therapies deemed necessary to provide comfort care or to alleviate pain.

B. A prehospital medical care directive shall be printed on an orange background and may be used in either letter or wallet size. The directive shall be in the following form:

Prehospital Medical Care Directive

(side one)

In the event of cardiac or respiratory arrest, I refuse any resuscitation measures including cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, administration of advanced cardiac life support drugs and related emergency medical procedures.
Patient: __________________________ date: ______________
(Signature or mark)
Attach recent photograph here
or provide all of the following
information below:
Date of birth ______ sex ____
Eye color ________ hair color ______ race ______
Hospice program (if any) ____________________
Name and telephone number of patient's physician ________
_________________________________________________________

(side two)

I have explained this form and its consequences to the signer and obtained assurance that the signer understands that death may result from any refused care listed above.
________________________________ date __________
(Licensed health care provider)
I was present when this was signed (or marked). The patient then appeared to be of sound mind and free from duress.
________________________________ date ___________

(Witness)

C. A person who has a valid prehospital medical care directive pursuant to this section may wear an identifying bracelet on either the wrist or the ankle. The bracelet shall be substantially similar to identification bracelets worn in hospitals. The bracelet shall be on an orange background and state the following in bold type:
Do Not Resuscitate
Patient: _________________________________________
Patient's physician: _____________________________

D. If the person has designated an agent to make health care decisions under section 36-3221 or has been appointed a guardian for health care decisions pursuant to title 14, that agent or guardian shall sign if the person is no longer competent to do so.
E. A prehospital medical care directive is effective until it is revoked or superseded by a new document.

F. Emergency medical system and hospital emergency department personnel who make a good faith effort to identify the patient and who rely on an apparently genuine directive or photocopy thereof on orange paper are immune from liability to the same extent and under the same conditions as prescribed in section 36-3205. If a person has any doubt as to the validity of a directive or the medical situation, that person shall proceed with resuscitative efforts as otherwise required by law. Emergency medical system personnel are not required to accept or interpret medical care directives that do not meet the requirements of this section.

G. In the absence of a physician, a person without vital signs who is not resuscitated pursuant to a prehospital medical care directive may be pronounced dead by any peace officer of this state, a professional nurse licensed pursuant to title 32, chapter 15 or an emergency medical technician certified pursuant to this title.
H. This section does not apply to situations involving mass casualties.
I. After being notified of a death by emergency medical system personnel, the person's physician or the county medical examiner is then responsible for signing the death certificate.

J. The office of emergency medical services in the department of health services shall print prehospital medical care directive forms and make them available to the public. The department may charge a fee that covers the department's costs to prepare the form. The department and its employees are immune from civil liability for issuing prehospital medical care directive forms that meet the requirements of this section. A person may use a form that is not prepared by the department of health services if that form meets the requirements of this section. If an organization distributes a prehospital medical care directive form that meets the requirements of this section, that organization and its employees are also immune from civil liability.

K. Any prehospital medical care directive prepared before April 24, 1994 is valid if it was valid at the time it was prepared.

L. For the purposes of this section, "emergency medical system personnel" includes emergency medical technicians at all levels who are certified by the department of health services and medical personnel who are licensed by this state and who are operating outside of an acute care hospital under the direction of an emergency medical system agency recognized by the department of health services.

Copyright 2001-2013 Galen Press, Ltd.