Durable Health Care Power Of Attorney Instructions And Form Page 12
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PREHOSPITAL MEDICAL CARE DIRECTIVE (DO NOT RESUSCITATE)
(IMPORTANT—T
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ORANGE B
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ACKGROUND)
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: A Prehospital Medical Care Directive is a document signed by you and your
ENERAL
NFORMATION AND
NSTRUCTIONS
doctor that informs emergency medical technicians (EMTs) or hospital emergency personnel not to resuscitate you.
Sometimes this is called a DNR – Do Not Resuscitate. If you have this form, EMTs and other emergency personnel will
not use equipment, drugs, or devices to restart your heart or breathing, but they will not withhold medical interventions that
are necessary to provide comfort care or to alleviate pain. IMPORTANT: Under Arizona law a Prehospital Medical Care
Directive or DNR must be on letter sized paper or wallet sized paper on an orange background to be valid.
You can either attach a picture to this form, or complete the personal information. You must also complete the form and
sign it in front of a witness. Your health care provider and your witness must sign this form.
1. My Directive and My Signature:
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 (Signature or Mark): ___________________________________________ Date: __________________________
OR
ATTACH RECENT PHOTOGRAPH HERE:
PROVIDE THE FOLLOWING INFORMATION:
My Date of Birth ________________________
___________________
My Sex
___________________
My Race
HERE
___________________
My Eye Color
___________________
My Hair Color
2. Information About My Doctor and Hospice (if I am in Hospice):
________________
Physician: __________________________________________________________ Telephone:
Hospice Program, if applicable (name): _________________________________________________________________
3. Signature of Doctor or Other Health Care Provider:
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.
Signature, Licensed Health Care Provider: __________________________________________ Date: _______________
4. Signature of Witness to My Directive:
I was present when this form was signed (or marked). The patient then appeared to be of sound mind
and free from duress.
Signature: ___________________________________________________________________ Date: ________________
_____________________________________________________________________________
______________________________________________________________________________________________________
Developed by the Office of the Arizona Attorney General
January 18, 2011
TOM HORNE
(All documents completed before January 18, 2011 are still valid)
)
PREHOSPITAL MEDICAL CARE DIRECTIVE (DNR
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