S ample Advance Dir ectives:

Transcription

1 S ample Advance Dir ectives: Durable P ow er of Attorney for Health Care (H ealt h Care P ow er of Attorney) Living W ill Prehospital Advance Directive Ar iz ona has perhaps the most modern advance dir ective law in the country. Simple and designed for people t o dow nload and use, Arizonans have succes s f u lly used t hes e documents for about a decade. T here ar e sever al unique things about these document s. 1. T her e is no requirement for patients to be " ter minal" (whatever that means ) to use them. 2. T hey can be used for childr en (such as those in home hospice progr ams) as w ell as adults. 3. T hey are ADVANCE DIRECTIVES, not physician orders. Patients initiate t hem. 4. T he pr ehospital advance dir ective law ("orange for m" ) has eliminated the unwanted and often accident al resuscitat ive efforts in dying patients. Few ot her states have such a pat ient -f r iendly device. [For additional information about this form, see: I serson KV: A simplified prehospital advance dir ect ive law : Arizona's approach. Ann Emerg Med 1993;22:11: ] S how these to your legislators! T here is no reason why your state can't have such s imple, usable, patient-f r iendly forms.

2 AR S S AMP L E HEALTH CARE POWER OF ATTORNEY Any writing that meets the r equir ements of section may be us ed to cr eate a health care power of attorney. The following for m is offered as a s ample only and does not prevent a per s on 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 cons ent to all medical, surgical, hospital and r elated health care. This power of attorney is effective on my inability to make or communicate health care decis ions. All of my agent's actions under this power during any period when I am unable to make or communicate health care decis ions or when there is uncertainty whether I am dead or alive have the s ame effect on my heirs, devisees and per s onal representatives as if I were alive, competent and acting for myself. I f my agent is unwilling or unable to s er ve or continue to s er ve, I hereby appoint as my agent. I have I have not completed and attached a living will for purposes of providing s pecific di r ecti on to my agent in situations that may occur during any period when I am unable to make or communicate health care decis ions 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 pr ehos pital medical care dir ective pur s uant to section , Arizona Revis ed S tatutes. T his health care dir ective is made under section , Arizona Revis ed S tatutes, and continues in effect for all who may rely on it except those to whom I have given notice of its revocation. S ignature of Principal Witness: Date: Time: Addr es s : Addr ess of Agent Witness: Telephone of Agent Addr es s : (Note: This document may be notar ized ins tead of being witnes s ed.) 2. Autopsy (under Arizona law an autopsy may be r equir ed) I f you wish to do s o, reflect your desires below: 1. I do not consent to an autopsy. 2. I consent to an autopsy. 3. My agent may give cons ent to or refuse an autopsy. (Continued on next page)

3 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 hos pital, 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 author ize your agent to do s o 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 s pace 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 author ity to make a gift of a par t of your body pursuant to law. Note: The donation elections you make in this health care power of attorney survive your death.) I f any of the s tatements below r eflects your desire, initial on the line nex t to that statement. You do not have to initial any of the s tatements. I f you do not check any of the s tatements, 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 s o. I have alr eady signed a wr itten agreement or donor card r egar ding or gan and tissue donation with the following individual or institution: Pursuant to Ar izona law, I hereby give, effective on my death: [] Any needed or gan or parts. [] The following par t or organs listed: for (check one): [] Any legally authorized pur pos e. [] Transplant or therapeutic pur pos es only. 4. Physician Affidavit (optional) (Before initialing any choices above you may wish to as k questions of your physician regarding a par ticular treatment alternative. If you do s peak with your physician it is a good idea to as k your physician to complete this affidavit and keep a copy for his file.) I, Dr. have r eviewed this guidance document and have discussed with any questions regarding the pr obable medical consequences of the tr eatment choices provided above. This discussion with the pr incipal occurred on. (date) I have agr eed to comply with the pr ovis ions of this directive. S ignature of Physician 5. Living Will (Optional. Section , Arizona Revis ed S tatutes, has a s ample living will.)

4 AR S S AMP L E LIVING W I L L Any writing that meets the r equir ements of this article may be us ed to cr eate a living will. A person may write and us e a living will without writing a health care power of attorney or may attach a living will to the per s on's health care power of attorney. If a per s on has a health care power of attorney, the agent must make health care decisions that are consistent with the per s on's known desires and that are medically reasonable and appr opr iate. A per s on can, but is not required to, state the per s on's desires in a living will. T he following for m is offered as a s ample only and does not prevent a per s on from using other language or another form: L iving W ill (S ome gener al statements concerning your health care options are outlined below. If you agree with one of the s tatements, you should initial that statement. Read all of these statements carefully before you initial your selection. You can also wr ite your own statement concerning life-sustaining tr eatment 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 ter minal condition I do not want my life to be pr olonged and I do not want life-sustaining tr eatment, beyond comfor t care, that would s er ve only to ar tificially delay the moment of my death. 2. If I am in a ter minal condition or an irreversible coma or a per s is tent vegetative state that my doctors reasonably feel to be irreversible or incurable, I do want the medical treatment necessary to pr ovide car e that would keep me comfor table, but I do not want the following: (a) Cardiopulmonary resuscitation, for example, the us e of drugs, electric s hock and artificial breathing. (b) Artificially administered food and fluids. (c) To be taken to a hos pital if at all avoidable. 3. Notwithstanding my other directions, if I am known to be pr egnant, I do not want life-sustaining tr eatment withheld or withdrawn if it is possible that the embr yo/fetus will develop to the point of live bir th with the continued application of life-sustaining tr eatment. 4. Notwithstanding my other directions I do want the us e of all medical care necessary to treat my condition until my doctors reasonably conclude that my condition is terminal or is irreversible and incur able or I am in a per s is tent vegetative s tate. 5. I want my life to be pr olonged to the gr eates t extent possible. Other or Additional Statements of Desires I have I have not attached additional special provisions or limitations to this document to be honor ed in the abs ence of my being able to give health care dir ections.

5 AR S : P R E H OS P I T AL MEDICAL CARE DIRECTIVES; FORM; EFFECT; DE F I NI T I ON A. Notwithstanding any law or a health care dir ective to the contr ar y, a per s on may execute a pr ehos pital medical care dir ective 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 pur pos es of this article, " cardiopulmonary resuscitation" shall include car diac compr ession, endotracheal intubation and other advanced air way management, artificial ventilation, defibrillation, administration of advanced car diac l i fe s uppor t drugs and r elated emer gency 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 neces s ar y to pr ovide comfor t care or to alleviate pain. B. A pr ehos pital medical care dir ective s hall be pr inted on an orange backgr ound and may be us ed in either letter or wallet size. The dir ective s hall be in the following form: Prehospital Medical Care Dir ective (side one) I n the event of cardiac or respiratory arrest, I refuse any resuscitation measures including cardiac compr es s i on, endotracheal intubation and other advanced air way management, artificial ventilation, defibrillation, administration of advanced car diac l i fe s uppor t drugs and related emer gency medical procedures. Patient: date: (S ignature or mark) Attach recent photograph here or provide all of the following information below: Date of birth sex Eye color hair color race Hospice pr ogr am (if any) Name and telephone number of patient's physician (side two) I have ex plained this form and its consequences to the s igner and obtained as s ur ance that the s igner understands that death may result from any refused car e listed above. date (Licensed health care pr ovider) I was present when this was signed (or marked). The patient then appeared to be of sound mind and fr ee fr om duress. date (Witness)

6 C. A per s on who has a valid pr ehos pital medical care dir ective pur s uant to this section may wear an identifying br acelet on either the wr is t or the ankle. The br acelet shall be substantially similar to identification bracelets worn in hospitals. The br acelet shall be on an orange backgr ound and s tate the following in bold type: Do Not Resuscitate Patient: Patient's physician: D. If the per s on has designated an agent to make health care decis ions under section or has been appointed a guar dian for health care decis ions pursuant to title 14, that agent or guardian shall sign if the per s on is no longer competent to do s o. E. A pr ehos pital medical care dir ective 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 r ely on an appar ently genuine dir ective or photocopy thereof on orange paper are immune fr om liability to the s ame ex tent and under the s ame conditions as prescribed in section If a per s on has any doubt as to the validity of a dir ective or the medical situation, that person shall proceed with resuscitative efforts as otherwise r equir ed by law. Emergency medical system personnel are not required to accept or interpret medical care dir ectives that do not meet the r equir ements of this section. G. In the abs ence of a physician, a per s on without vital signs who is not resuscitated pursuant to a pr ehos pital medical care dir ective may be pr onounced dead by any peace officer of this state, a pr ofessional nurse licensed pur s uant to title 32, chapter 15 or an emergency medical technician certified pur s uant to this title. H. This section does not apply to s ituations involving mass casualties. I. After being notified of a death by emergency medical system personnel, the per s on's physician or the county medical examiner is then responsible for signing the death certificate. J. The office of emergency medical services in the depar tment of health services shall print prehospital medical care dir ective for ms and make them available to the public. The department may charge a fee that covers the depar tment's costs to pr epar e the for m. The department and its employees are immune fr om civil liability for issuing pr ehos pital medical care dir ective for ms that meet the r equir ements of this section. A per s on may use a for m that is not prepared by the depar tment of health services if that form meets the requirements of this section. If an organization distributes a pr ehos pital medical care directive for m that meets the r equir ements of this section, that organization and its employees are als o immune fr om civil liability. K. Any prehospital medical care dir ective pr epar ed befor e Apr il 24, 1994 is valid if it was valid at the time it was prepared. L. For the pur pos es of this section, "emergency medical system personnel" includes emergency medical technicians at all levels who ar e cer tified by the depar tment of health services and medical personnel who ar e licensed by this state and who ar e oper ating outside of an acute car e hos pital under the dir ection of an emergency medical system agency recognized by the depar tment of health services.