Medical Directive - DNR

ARIZONA PREHOSPITAL MEDICAL CARE DIRECTIVE PREPARATION WORKSHEET

Not the Orange DNR Form

CRITICAL NOTICE: This Markdown worksheet is not a valid Arizona prehospital medical care directive. A.R.S. § 36-3251 requires the directive to be printed on an orange background in letter or wallet size and to contain the statutory form information and signatures. Use the current form distributed by the Arizona Attorney General or another form that satisfies the statute.

Use this worksheet to collect information and prepare for execution of the official orange form.

1. PERSON INFORMATION

The statutory form requires either a recent photograph or all requested identifying information. Confirm which option will be used:

☐ Recent photograph attached

☐ Date of birth, sex, race, eye color, and hair color completed

2. REQUEST FOR DISCUSSION

I request a discussion with a licensed Arizona health care provider about completing a prehospital medical care directive.

If I experience cardiac or respiratory arrest, my current preference is to refuse the resuscitation measures listed in A.R.S. § 36-3251, including cardiac compression, advanced-airway management, artificial ventilation, defibrillation, advanced cardiac life-support drugs, and related emergency procedures.

I understand that the directive does not withhold other interventions deemed necessary for comfort care or pain relief, such as intravenous fluids or oxygen.

Questions, values, or treatment preferences:

[____________________________________________________________]

[____________________________________________________________]

Person or information-provider signature: [________________________________]

Printed name and relationship: [________________________________]

Date: [__/__/____]

This signature records preparation only. Sign or mark the official orange directive in the presence of the required witness or notary.

3. WHO WILL SIGN FOR THE PERSON

Signer: ☐ Person with capacity ☐ Health-care agent ☐ Court-appointed guardian

If the person is no longer competent, A.R.S. § 36-3251(D) requires the designated health-care agent or appointed health-care guardian to sign.

Agent or guardian name: [________________________________]

Authority document: [________________________________]

Date and medical-record location: [________________________________]

☐ Authority reviewed before execution

☐ Current directive is consistent with known instructions and the signer’s authority

4. LICENSED HEALTH CARE PROVIDER REVIEW

Provider name: [________________________________]

Profession and Arizona license number: [________________________________]

Review date: [__/__/____]

☐ I am a “health care provider” within the current definition in A.R.S. § 36-3201(7).

☐ I explained the form and its consequences to the signer.

☐ I obtained assurance that the signer understands that death may result from the care refused on the directive.

☐ The official orange form was completed separately.

Provider signature on this worksheet: [________________________________] Date: [__/__/____]

The statutory form requires a licensed health care provider's dated signature. Do not limit the signer category to only a physician, nurse practitioner, or physician assistant; confirm the current definition in A.R.S. § 36-3201(7).

5. EXECUTION REQUIREMENTS FOR THE OFFICIAL FORM

Before relying on the directive, confirm every item:

☐ Orange background

☐ Letter or wallet size

☐ Required refusal language

☐ Person's signature or mark, or authorized agent or guardian signature when applicable

☐ Date of signature

☐ Recent photograph or all required identifying information

☐ Hospice information, if applicable

☐ Physician name and telephone number

☐ Dated signature of a licensed health care provider

☐ Dated signature of one qualified witness or notarial jurat, following the current Attorney General form

The Attorney General's current instructions state that the witness or notary must not be under 18, related by blood, adoption, or marriage, entitled to the person's estate, appointed as the person's agent, or involved in providing the person's health care when the form is signed.

Use a witness or a notary, not both, when following the current Attorney General form. This is not a two-witness document.

6. COPIES, DISPLAY, AND OPTIONAL BRACELET

• Display the orange form where first responders can readily find it.
• A.R.S. § 36-3251(F) protects qualifying reliance on an apparently genuine directive or a photocopy on orange paper. The statute does not say that a phone image or ordinary-color electronic copy substitutes for the orange document.
• If there is doubt about the directive's validity or the medical situation, personnel must proceed with resuscitation as otherwise required by law.
• A person with a valid directive may wear the optional statutory identification bracelet on the wrist or ankle. It must be on an orange background and identify “Do Not Resuscitate,” the patient, and the patient's physician.
• The statute provides for a bracelet, not a necklace.

Checklist:

☐ Original orange directive placed in visible, accessible location

☐ Any working photocopy printed on orange paper

☐ Family, caregivers, hospice, and facilities told where the directive is kept

☐ Optional statutory bracelet completed accurately and worn on wrist or ankle

7. SCOPE AND STATUTORY EXCEPTIONS

The directive applies to withholding CPR in cardiac or respiratory arrest. It does not authorize withholding comfort care or pain-relieving interventions.

A.R.S. § 36-3251 does not apply to:

• mass-casualty situations; or
• medical emergencies involving children and adults with disabilities in public or private schools that are not licensed health-care institutions.

Direct-care staff may comply under § 36-3251(L) when the person's physician has ordered a hospice plan of care.

8. REVOCATION OR REPLACEMENT

A prehospital medical care directive remains effective until revoked or superseded by a new document. Under A.R.S. § 36-3202, a person may revoke the person's health care directive by:

• a written revocation;
• oral notice to the surrogate or a health care provider;
• a new health care directive; or
• another act demonstrating a specific intent to revoke.

Do not use this worksheet as the revocation itself. Immediately notify the agent or guardian, licensed provider, caregivers, hospice, and facilities; remove superseded orange forms and bracelets from active use; and document the change.

Date change requested: [__/__/____]

Person notified: [________________________________]

Action taken and record location:

[____________________________________________________________]

9. IMMUNITY AND RELIANCE

A.R.S. § 36-3251(F) incorporates the immunity standards of § 36-3205 for qualifying personnel who make a good-faith identification effort and rely on an apparently genuine compliant directive or orange-paper photocopy. Section 36-3205 addresses good-faith reliance and does not relieve a provider from liability for unrelated negligent treatment.

Do not replace these statutory standards with a patient indemnity, release, liability cap, attorneys' fees clause, forum-selection clause, or private enforcement remedy.

10. OFFICIAL SOURCES

• A.R.S. § 36-3251 — https://www.azleg.gov/ars/36/03251.htm
• A.R.S. § 36-3201 — https://www.azleg.gov/ars/36/03201.htm
• A.R.S. § 36-3202 — https://www.azleg.gov/ars/36/03202.htm
• A.R.S. § 36-3205 — https://www.azleg.gov/ars/36/03205.htm
• Arizona Attorney General, Life Care Planning — https://www.azag.gov/issues/elder-affairs/life-care-planning
• Arizona Attorney General, Prehospital Medical Care Directive — https://www.azag.gov/sites/default/files/2025-03/DNR%20-%20White%20Background.pdf

Verify the current statute, official orange form, provider qualification, and local EMS or facility protocol before relying on a prehospital medical care directive.