THE PREHOSPITAL MEDICAL CARE DIRECTIVE OR “DNR” — IT’S NOT FOR EVERYONE

A few weeks back an item appeared in the Arizona Daily Star suggesting that there seems to be a “conspiracy of silence” concerning Arizona law on the prehospital medical care directive, also known as a “do-not-resuscitate” instruction or “DNR.” I have been asked about it a number of times recently, perhaps due to the newspaper item.  The law on it is actually quite clear, although it does seem that relatively few people are aware of it.

The term “prehospital medical care directive” is actually not very accurate, since the directive deals only with cardiopulmonary resuscitation in the event of cardiac or respiratory arrest.  The term “do not resuscitate” instruction is actually a much more accurate description of what it’s about.

Section 36-3251 of the Arizona Revised Statues lays out the basic terms for a prehospital medical care directive quite clearly:

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.

. . .

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.

The next part of the statute specifies what the prehospital medical care directive must say, and that it must be on orange paper:

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)

The statute also says that a person who has a valid prehospital medical care directive “may wear an identifying bracelet on either the wrist or the ankle,” which “shall be substantially similar to identification bracelets worn in hospitals [and] shall be on an orange background and state… in bold type… Do Not Resuscitate” with the person’s name and the name of their physician.  So if you have a signed prehospital medical care directive that meets the requirements of the statute, you can also wear a bracelet to let medical care providers know that you don’t want to be resuscitated.

According to the legislative history, the statute that provides for the prehospital medical care directive was first adopted in 1992.  I believe that I can count on the fingers of one hand the number of times that I have prepared a prehospital medical care directive in the last fifteen years.  Usually the people who ask about it decide they don’t want it once I explain what it means.

Here’s how I describe what the prehospital medical care directive means:  it means that when the paramedics come to your house and find you unconscious and not breathing, as soon as they see the orange “DNR” on your refrigerator, they leave.

It’s a personal choice, of course. There are perfectly legitimate reasons why some people think the DNR instruction is a good idea.  Usually, however, the people I talk to are more comfortable with a living will, which is a more general statement to control the health care treatment decisions that can be made on behalf of the person signing the living will.  I covered the living will in my March, 2005, Special Report. I’ll revisit the topic in a future report.

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