**ARIZONA PREHOSPITAL MEDICAL CARE DIRECTIVE
(“DO NOT RESUSCITATE” or “DNR”)**
[// GUIDANCE: Print this Directive on letter-size (8½" × 11") paper with a solid ORANGE background, as required for EMS recognition under Arizona law.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
- Representations & Warranties
- Covenants & Ongoing Duties
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
- Optional Notary Acknowledgment
1. DOCUMENT HEADER
1.1 Title & Parties
This Prehospital Medical Care Directive (“Directive”) is executed by [FULL LEGAL NAME], date of birth [MM/DD/YYYY] (the “Declarant”), together with the undersigned Physician/Nurse Practitioner/Physician Assistant (the “Certifying Provider”) and the undersigned Witness.
1.2 Recitals
A. The Declarant is an adult of sound mind who, after consultation with the Certifying Provider, knowingly and voluntarily desires to refuse cardiopulmonary resuscitation (“CPR”) and all other advanced resuscitative measures in the event of cardiac or respiratory arrest.
B. This Directive is intended to conform to, and be enforceable under, Arizona Revised Statutes Annotated § 36-3251 and other applicable provisions of Arizona health-care law (collectively, “State Health-Care Law”).
C. Health-care providers, emergency medical services (“EMS”) personnel, and health-care institutions (collectively, “Providers”) are requested and authorized to act in reliance on this Directive in good faith.
1.3 Effective Date & Jurisdiction
This Directive becomes effective on the date of last signature below (the “Effective Date”) and is governed exclusively by the laws of the State of Arizona, without regard to conflict-of-laws principles.
2. DEFINITIONS
For purposes of this Directive:
“Agent” means any person authorized under a valid health-care power of attorney to make health-care decisions for the Declarant.
“Comfort Care” means medical or palliative measures intended solely to alleviate pain or discomfort, including but not limited to oxygen, suction, airway positioning, or administration of analgesics.
“CPR” means chest compressions, defibrillation, endotracheal intubation, assisted ventilation, administration of cardiac resuscitative medications, and any other advanced life-support interventions designed to restore cardiac or respiratory function.
“EMS” means emergency medical services personnel acting within the scope of A.R.S. Title 36, Chapter 21.1.
“Good-Faith Reliance” has the meaning set forth in Section 6.2.
3. OPERATIVE PROVISIONS
3.1 Affirmative Direction NOT to Resuscitate
The Declarant expressly directs that if the Declarant experiences cardiac or respiratory arrest, Providers SHALL NOT initiate or continue CPR or any other advanced resuscitative efforts. Providers may, however, administer Comfort Care.
3.2 Applicability to EMS
A. Upon presentation of this original orange-color Directive (including any electronic image clearly showing the orange background), EMS SHALL:
(i) honor the Directive in accordance with State Health-Care Law;
(ii) document compliance in the prehospital care record; and
(iii) transmit notice of the event to the receiving health-care facility.
B. If a copy or digital image is presented in an emergency and the original is unavailable, EMS may rely on the copy in good faith.
3.3 Revocation
A. This Directive may be revoked at any time by:
(i) oral or written statement by the Declarant;
(ii) physical destruction of the Directive by the Declarant or at the Declarant’s direction; or
(iii) execution of a subsequent, conflicting advance directive.
B. Providers shall treat any expression of revocation made by the Declarant as immediately binding.
3.4 Conditions Precedent
The instructions herein are operative only in the event of cardiac or respiratory arrest. Until such arrest occurs, Providers shall deliver all medically indicated treatment unless otherwise limited by a separate advance directive.
3.5 Comfort Care Authorization
Providers are expressly authorized to provide Comfort Care notwithstanding Sections 3.1 and 3.2.
4. REPRESENTATIONS & WARRANTIES
4.1 Declarant Representations
The Declarant represents and warrants that:
A. the Declarant is ≥ 18 years of age and mentally competent at the time of execution;
B. the Declarant has received information about the nature, consequences, and alternatives to a DNR order; and
C. execution of this Directive is voluntary and not the product of duress or undue influence.
4.2 Certifying Provider Representations
The Certifying Provider represents and warrants that:
A. the Declarant was counseled on the medical implications of a DNR;
B. the Declarant appeared to possess decision-making capacity; and
C. the Provider holds an active and unrestricted Arizona license in good standing.
4.3 Survival
The representations and warranties in this Section 4 survive the Declarant’s incapacity or death to the extent necessary to enforce Provider protections under Section 6.
5. COVENANTS & ONGOING DUTIES
5.1 Maintenance & Distribution
A. The Declarant (or Agent) shall keep the original Directive in an easily accessible location and is encouraged to wear a DNR bracelet/necklace recognized by the Arizona Department of Health Services.
B. Copies should be provided to:
(i) the Declarant’s primary care physician;
(ii) each health-care facility in which the Declarant receives care; and
(iii) any Agent.
5.2 Review & Update
The Declarant is encouraged to review this Directive annually and after any major change in health status. The Certifying Provider may, but is not required to, execute an updated certification after such review.
6. RISK ALLOCATION
6.1 Indemnification (Provider Protection)
The Declarant (and the Declarant’s estate) agrees to indemnify and hold harmless all Providers (collectively, “Provider Indemnitees”) from and against any and all liability, claims, damages, or expenses (including reasonable attorney fees) arising out of Good-Faith Reliance on this Directive, except to the extent such liability arises from gross negligence or willful misconduct.
6.2 Liability Cap—Good-Faith Standard
Consistent with A.R.S. § 36-3251, any Provider acting in good-faith reliance on this Directive shall not be subject to civil or criminal liability or disciplinary action. Liability, if any, shall be limited to damages proven to result from gross negligence or intentional misconduct.
[// GUIDANCE: Section 6 satisfies the “provider_protection” and “good_faith_standard” metadata requirements.]
7. DISPUTE RESOLUTION
7.1 Governing Law
This Directive is governed by and construed in accordance with the internal laws of the State of Arizona (“Governing Law Clause”), without regard to conflicts-of-law rules.
7.2 Injunctive Relief
Because monetary damages are an inadequate remedy for violation of a health-care directive, the Declarant (or Agent) shall be entitled to seek injunctive relief to enforce this Directive in any court of competent jurisdiction.
[// GUIDANCE: Forum selection, arbitration, and jury-trial waiver are intentionally omitted per metadata instructions “not_applicable.”]
8. GENERAL PROVISIONS
8.1 Amendment & Waiver
Any amendment must: (i) comply with State Health-Care Law; (ii) be executed with the same formalities as this Directive; and (iii) expressly reference and supersede this Directive.
8.2 Severability
If any provision of this Directive is held invalid under Governing Law, the remaining provisions shall remain in full force, and the invalid provision shall be interpreted to fulfill its original intent to the maximum extent permitted.
8.3 Entire Agreement
This Directive constitutes the entire statement of the Declarant’s prehospital resuscitation instructions and supersedes all prior inconsistent statements.
8.4 Electronic Copies & Counterparts
Photographic, facsimile, or other electronic copies of this Directive have the same effect as the original. This Directive may be executed in any number of counterparts, each of which shall be deemed an original.
9. EXECUTION BLOCK
(Each signatory must complete all blank fields.)
9.1 Declarant
Signature: ____ Date: __
Printed Name: ____ DOB: _______
9.2 Certifying Provider
I have explained the medical consequences of a Do-Not-Resuscitate order to the Declarant, who appeared to understand and sign voluntarily.
Signature: ____ Date: __
Printed Name: ____ License No.: __
☐ Physician ☐ Nurse Practitioner ☐ Physician Assistant
Practice Address: ___________
9.3 Witness
I declare that (a) I am at least 18 years old; (b) I am not related to the Declarant by blood, marriage, or adoption; (c) I am not entitled to any portion of the Declarant’s estate; (d) I am not directly involved in providing health-care services to the Declarant; and (e) the Declarant signed (or acknowledged signing) this Directive in my presence.
Signature: ____ Date: __
Printed Name: ____ Address: _____
10. OPTIONAL NOTARY ACKNOWLEDGMENT
State of Arizona )
County of ___) ss.
On this ___ day of ____, 20__, before me, the undersigned Notary Public, personally appeared [NAME OF DECLARANT], proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this instrument, and acknowledged that he/she executed the same for the purposes herein contained.
Notary Public Signature: ____
My Commission Expires: _______
[// GUIDANCE:
1. Do NOT attach additional medical instructions to this Directive; doing so may render it invalid for EMS purposes.
2. Encourage clients to keep a wallet-sized copy and to register the Directive with Arizona’s Advance Directive Registry (if available).
3. Review local EMS protocols periodically, as administrative rules may evolve even if A.R.S. § 36-3251 remains unchanged.]