Special Purpose Forms:
Attachments for the Living Will & Health Care Power of Attorney and the Prehospital
Medical Care Directive
This page introduces a PDF file containing special forms that some people will
want to add to their Living Will and Health Care Power of Attorney.
Special Purpose Forms described on this page:
The orange Prehospital
Medical Care Directive (PMCD) form for refusing CPR under all circumstances
My wishes should I be pregnant when my directive
is in effect An attachment to Living Will & Health Care Power of Attorney.
Disqualification of Statutory
Surrogates An attachment to Living Will & Health Care Power of Attorney.
Refusal of all life-sustaining
treatment because of current poor quality of life An attachment to Living Will &
Health Care Power of Attorney.
Download the above Special Purpose Forms
The Prehospital Medical Care Directive (the "orange form") is used to direct
emergency medical personnel not to administer cardiopulmonary resuscitation (CPR). Arizona
law provides two formats for the orange form. One is a full page format and the other is
"wallet card" size. Both contain the same information. You may also wear an
orange hospital style band around with the words " Do Not Resuscitate,"
your name, and your doctors name on it to indicate that you have completed an orange form.
Use the orange form (page or card format) only if you do not want to be
resuscitated at any time, under any circumstances.
The orange form is different from a Living Will. A Living Will typically directs that
one be allowed to die only if conditions described in the document are met. The orange
form contains no such conditions. The "orange form" can prevent an Emergency
Medical Technician (EMT) from using CPR to attempt to restore heartbeat and breathing
regardless of what the outcomes believed to be possible.
Any competent adult may complete an orange form, and many do for good reasons. Just be
certain that you understand what this form does before you complete it. Emergency
personnel who are summoned will still perform needed comfort measures or emergency
procedures other than CPR. This includes providing transport to a hospital where necessary
and wanted by the patient.
Only the page format orange Prehospital Medical Care Directive master is
available from this web site. Remember valid orange forms and copies must be on orange
paper! Orange forms, orange cards, and orange bands may be ordered from Dorothy Garske
Center through regular mail. These items are on the Price List.
Return to the top of this page
This attachment to the Living Will & Health Care Power of Attorney enables a women
of child bearing aging to state her wishes should illness or injury leave her in a
condition she would consider an unacceptable quality of life. The choice comes down to
this: would you wish to endure or not endure an unacceptable quality of life if you
probably could be kept alive long enough to bear a health baby? Because the decision of a
pregnant woman or her surrogates to refuse life-sustaining treatment will be resisted by
many, it is essential that this preference be documented and discussed in advance.
Return to the top of this page
This attachment to the Living Will & Health Care Power of Attorney is available
because Arizona law requires physician's to attempt to locate a "surrogate"
whenever a patient is unable to make her or his own health care decisions. The first
surrogate the physician will try to find is a health care agent or a court appointed
guardian. If neither are available, a physician must select the first available person or
persons from this list:
1. The patient's spouse, unless the patient and spouse are legally
separated.
2. An adult child of the patient. If the patient has more than one adult child, a
majority of the adult children.
3. A parent of the patient.
4. If the patient is unmarried, the patient's domestic partner if no other person has
assumed any financial responsibility for the patient.
5. A brother or sister of the patient.
6. A close friend of the patient who has exhibited special care and concern for the
patient, who is familiar with the patient's health care views and desires and who is
willing and able to become involved in the patient's health care and to act in the
patient's best interest.
A problem could occur if efforts to locate a surrogate lead to the appointment of
someone who does not agree with your choices. Be certain that all potential surrogates
would support your choices or defer to another who would. All surrogates are required to
follow your living will. Nonetheless, it is advisable to disqualify in writing any
potential surrogate who would not support your choices. You can do this on your document
or with the form provided.
Return to the top of this page
This attachment to the Living Will & Health Care Power of Attorney is designed for
persons with degenerative chronic conditions that already cause great discomfort or pain.
This is different from the option for current refusal of all life sustaining treatment
included in the Living Will & Health Care Power of Attorney form itself. That option
is for people of advanced age.
Some physicians and family members will resist allowing a reversible life-threatening
condition (such as an infection) to take the life a non-comatose young adult. It is
important that anyone wanting exercise this choice clearly document the basis for her or
his choice. It is critical that such a choice be discussed with health care agents, family
and physicians.
Return to the top of this page
* return to Overview *
home *
|