a simplified prehospital advance directive law: arizona's approach

CONCEPTS advance directives death certificates emergency medical services resuscitation orders

A Simplified Prehospital Advance Directive Law: Arizona's Approach

From the Arizona Bioethics Program and Section of Emergency Medicine, Department of Surgery, University of Arizona College of Medicine, Tucson.

Received for publication July 6, 1992. Revision received December 2, 1992. Accepted for publication December 17, 1992.

Kenneth V Iserson, MD, MBA, FACEP

See related editorial, p 1748,

Many of the approximately 400,000 deaths that occur outside of hospitals or chronic care facilities each year in the United States are not only expected but also welcomed as relief from terminal disease. However, patients who lack decision-making capacity cannot communicate to emergency medical services system and emergency department personnel their wish not to be the recipient of advanced life support procedures. Prehospital advance directives (PHAD) offer that opportunity. Arizona is only the fourth state to pass a PHAD statute and the first to simplify the law so it is interpreted easily by both providers and patients. PHAD laws need not be complex, either in their language or in their implementation requirements. Simple and easily understood statutes and their resulting directives increase the likelihood that those most likely to need and use this directive will be able to comply with its provisions. Arizona's law address- es several controversial areas yet to be worked out by other states. Placing the PHAD in statute ensures that a statewide attempt will be made to comply with its provisions, and as a law it should be more permanent than advance directive protocols based on administrative fiat. Physicians in other states may want to follow Arizona's lead and employ a joint effort by their state's bar association, hospital association, and medical association to smooth the passage of similar legislation. All parties involved, however, must not seek a perfect statute. Arizona's experience suggests that legislators will need to strike a balance between the needs of the citizens and the fears of lawyers wary of any potential liability for the state or the emergency medical services system.

[Iserson KV: A simplified prehospital advance directive law: Arizona's approach. Ann Emerg Med November 1993;22:1703- 1710.]

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ADVANCE DIRECTIVE Iserson

INTRODUCTION

Approximately 400,000 people die outside of hospitals or chronic care facilities each year in the United States. 1,2 Although manY of these deaths are not only expected but also welcomed as relief from a terminal disease, some of these patients still receive advanced life support (ALS) procedures from emergency medical services (EMS) system and emergency department personnel. These attempts at what may be unwanted resuscitative efforts are performed with the knowledge that the real purpose of cardiac resuscitation is to prevent "sudden unexpected death...not [for] cases of terminal irreversible illness where death [was] not unexpected. ''3 One reason these resuscitations occur is the lack of advance directives that can be interpreted rapidly by EMS providers or emergency physicians. Another cause is antiquated EMS protocols that require resuscitation except where death is grossly obvious to a layman (eg, decapitation, decomposition, iivor or rigor mortis, charring beyond recognition, or massive injury to the heart, lungs, or brain that is incom- patible with life). 4

Hospital personnel have long understood the limitations of cardiac resuscitative attempts for their patients. The American Heart Association noted, "It was not too long [after the introduction of CPR techniques] before CPR was performed almost reflexively, so much so that a mechanism had to be developed to prevent resuscitative efforts in patients who were hopelessly ill. 'Do Not Resuscitate' or 'Care and Comfort Only' orders were invoked.'2 They go on to state that "'Prolongation of life,' as used in the Saikewicz case, does not mean a mere suspension of the act of dying, but contemplates, at the very least, a remission of symptoms enabling a return toward a normal, functioning, integrated existence. ''2 As EMS personnel began to realize the importance of not performing unwanted resuscitations, their systems gradually adopted prehospital advance directive (PHAD) protocols.5-9

What elements are necessary in a PHAD? A PHAD protocol or statute must detail when such a document could be used, the document's wording, how to inform EMS personnel about the document's existence, and the liability protection for practitioners who comply with the PHAD~ provisions. Although it may be difficult to enact PHADs in state statutes, PHADs are proliferating through law or protocol in states and EMS regions throughout the United States. Montana passed the first statewide PHAD legislation in 1991,.and New York and Colorado quickly followed. 10-12 At least two statewide PHAD systems exist by administrative fia{,'and other states are in the process

of developing a PHAD system.13,14 Arizona recently enacted a PHAD article into law during the revision of its general advance directives statute. 15. The approach the drafters took and the nature of the,document may serve as a model for others who are trying to implement similar statewide statutes.

PREHOSPITAL ADVANCE DIRECTIVES

What Are Advance Directives? Advance directives are instructions from a patient or legal surrogate to providers of medical care, usually asking them not to initiate life- prolonging measures. They might better be called "no extraordinary treatment" instructions. At the least, they usually include a request not to perform CPR. This is vital because CPR is the only medical procedure that virtually anyone can perform, yet once started it usually needs a physician's order, in the medical institution or EMS system, to stop. Other advance directive elements can vary, but often include instructions not to intubate, not to place the patient on a ventilator, or not to electrically shock the heart. Occasionally, it also will include instructions to avoid using certain parenteral medications, artificial nutrition or hydration, or other measures.

Within a health care facility, advance directives trans- form into do-not-attempt-resuscitation or limitation-of- treatment orders that must be executed by a licensed physician. In general, such an order must be written only with the consent of the patient, a legal guardian, legally approved family members, or the court; the specific individuals who may give consent to a do-not-attempt-resuscitation order for an incompetent patient vary by jurisdiction. Yet, in critical situations of acute onset, such as those seen by EMS providers and ED personnel, previously established legal dependency is rare except for the parent- minor child relationship. This situation leads emergency medicine, critical care, and other hospital-based clinicians to face difficult decisions when patients known to have terminal and rapidly deteriorating diseases are hospitalized without any prior physician-patient discussions or decisions regarding the aggressiveness of care. Relatives who are asked to consent to procedures often are not legally able to do so and thus are not able to refuse such potentially life-saving procedures as resuscitation; such a refusal might be predicated on the emotional or financial burden produced by a prolonged illness. 16,17 Prior instructions from the patient or surrogate would appear to be the optimal solution.

*Copies of this statute may be obtained from the author.

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What Is a PHAD? As prehospital care has flourished in the United States over the past two decades, the increas- ingly sophisticated 911-dispatched EMS systems are capable of delivering ALS techniques that were not available in many hospitals a generation ago. These EMS personnel have limited training about ethical issues and usually must operate under a strict set of protocols set up by the state or local EMS governing body. 4 This limits their options in the field and leads to situations where intensive critical care procedures must be used, by protocol, on out-of-hospital patients in extremis or in cardiac arrest any time the ambulance service is activated, s The most common situation nationwide is that prehospital care providers must provide full resuscitative care for all patients in cardiac or respiratory arrest for whom they are cafled.<7, ~s-25 Primary care providers have been unable to prevent unwanted resuscitation of homebound or nursing home patients by emergency responders. PHADs are EMS-specific forms designed to allow patients to refuse EMS care, even if the EMS is activated inadvertently. As of 1990, only about 21 EMS regions in the United States had PHAD protocols, is

How Do PHADs Work? The EMS system works best if it is not activated in cases in which resuscitative efforts are not desired; once the system is activated, PHADs are necessary to avoid unwanted interventions. In most states, EMS personnel are not authorized to pronounce patients dead and are required to attempt resuscitation with all of the modalities at their disposal except in the most obvious cases of death. A patient with appropriate decision-making capacity may always refuse medical care from either physicians or EMS personnel if the refusal does not threat- en basic societal interests (eg, preservation of life, preven- tion of homicide and suicide, protection of interests of innocent third parties, and preservation of the integrity of the medical profession). 26-29 The federal Patient Self- Determination Act requires that patients be informed of this right on entering a health care facility. 3o However, a patient who does not have decisionrmaking capacity gives implied consent to emergency treatment if no acceptable advance directive is present. "Acceptable" in this sense means an advance directive that the EMS personnel have been trained to interpret and that is applicable to the prehospital setting.

Existing PHAD protocols range from being very restrictive in the scope of patients allowed to participate and in their implementation s9 to those that are more liberal.aa, 23 Maryland's PHAD protocol requires that patients have a terminal illness, have a life expectancy of six months or less, and be under the care of a hospice program (but not

necessarily be in the hospice). A "hospice card" with detailed information must be with the patient when the paramedics arrive, and a separate confirmation of identity is required. 10 In Anchorage, Alaska, however, everyone except those in long-term facilities (for legal reasons) may complete a PHAD that the EMS system finds very simple to implement. 23

If PHAD protocols are not in place, patients without decision-making capacity may be transported against their will to an ED to have resuscitative efforts continued. Emergency physicians, with their commitment to universal care for life-threatening conditions and the time constraints necessary to perform a successful resuscitation, are ill equipped to assess the validity of an advance directive other than a PHAD. They therefore follow a universal rule of health law--"treat first and ask legal questions later. ''31 It often falls to critical care physicians in the ICU, with the help of a hospital attorney, to evaluate such non-PHAD documents. If they are found to be valid, life support then may be withdrawn--but only after inflicting the added pain, expense, and anguish of superfluous interventionsP

What Are the Potential Benefits of PHAD Protocols? Implementing PHAD protocols lessens the emotional strain on EMS personnel when it is clear that their efforts are not only useless but also unwanted by their patient. The Anchorage PHAD protocol notes that "emotional risk is an occupational hazard in EMS, so much so that actual grief reactions on the part of the EMT occur with distress- ing frequency. Ironically, the sense of personal loss linked to certain calls does not coincide with patient outcome. Successfully reviving a patient who is known to be terminally ill, or survives to endure an empty existence, can cost the responder much more emotionally than losing the patient .... Failure to grasp and fulfill our patients' needs deprives us of one of the sustaining rewards of EMS work. ''32 The Alaskans also noted that PHAD protocols had as "... a valuable side effect the potential reduction in several intangible costs that accompany these calls: conflicts at the scene, skewed response patterns, and self-esteem decay surrounding treatment of hopelessly ill patients. ,,32

DRAFTING THE LAW: MULTIPLE CONSTITUENCIES

Arizona's first Living Wil l law went into effect in September 1985) 3 It contained only a living will, several restrictions on its use, and no durable power of attorney for health care. This law was modified in 1991, and a legislative study committee (ten public members and six


ADVANCE DIRECTIVE Isersot~

legislators) was authorized to suggest further changes to the next legislature. >

In November 1990, before any legislative activity, the Arizona Medical Association, Arizona Hospital Association, and State Bar of Arizona formed a small joint committee to draft a proposed new law. This committee was an ad hoc subcommittee of the Arizona Medical Association's Committee on Bioethics. The group was composed of four physicians (neonatology/bioethicist, geriatrics, emergency medicine/bioethicist, intensive care), four lawyers (two elder care lawyers, one county fiduciary, one attorney representing the Arizona Hospital Association), and the legislative liaison for the Arizona Medical Association. The group settled on an initial draft within the limited time period before the legislature formed its committee. This draft was scrutinized by their parent bodies and additional constituencies, including representatives from long-term care, the American Association of Retired Persons, home health nurses, and a citizens' health advisory group. The final draft inc luded a durable" powe r of attorney for health care with optional guidance sections to give an agent direction about organ donation and autopsy, a living will for use either as a guide for a surrogate (agent) or separately, a list of surro- gates who could make decisions if no advance directive is available, a PHAD, and a section relieving providers of liability for complying with the statute. The draft legislation was submitted to the legislative study committee and quickly adopted as their working document.

While a number of controversial areas not yet worked out on a national basis have yet to be clarified, one area in which there was firm agreement from the outset was the need for a standard statewide PHAD form. As Crimmins noted recently, "A critical component of aDNR system is ensuring the validity of a DNR order by using...standard- ized forms. ''35 Arizona's PHAD form is statutorily mandated in a full-size and a wallet-size format.

CONTROVERSIAL AREAS

To avoid errors, existing PHAD protocols generally adhere ~o the principle that "to protect the public interest procedures are designed so that any errors will lean in the direction of administrative caution.'32 One emergency physician wrote that "initiation of cardiopulmonary resuscitation when the death is the result of an end-stage, irreversible, and imminently terminal illness against the patient's prior request is immoral and indefensible. "35 Too many restrictions on the use of PHADs, however, may condemn some people to a prolonged or unwanted dying

process. The authors of this legislation, as welt as many who testified before the legislative panel, believed that the good resulting from easily used PHADs clearly outweighs a minuscule number of occasional .errors from accidentally omitted resuscitations in end-of-life situations.

Twelve controversial areas commonly confronted by drafters of PHAD statutes and protocols were debated while developing and passing this legislation. Definitions of key terms and liability issues were problematic within the entire bill, although government liability was raised only in relation to the PHAD. Unique issues in the PHAD included the method of patient identification, the options in limiting care, the involvement of health care providers in completing the PHAD, decisional capacity, witnesses and revocation, methods of death pronouncement, the level of EMS provider who could comply with the document, base station control, and the document's use in EDs.

Terminal Illness The question of what constitutes a

"terminal illness" is a sticking point in the adoption and implementation of most advance directive legislation. Most state statutes restrict the use of advance directives to adults with terminal diseases, and the American College of Emergency Physicians recommends that a PHAD "attesting to a patient's terminal illness" be available to EMS personnel.29, 36 What, however, is a terminal disease? Should it be defined in terms of a person's longevity, debilitation, or sentience, or by other factors? Prehospital care and EMS providers have expressed concerns that without strict limitations, PHADs may be used not only tO avoid prolongation of a certain death from a terminal disease but possibly also to assist a suicide by a mentally unstable individual or to abet a murder by potential heirs or a disgruntled spouse. Yet, determining whether a PHAD was executed for reasons consistent with legal and moral guidelines could prove to be very difficult, if not impossible.3r

The respect for persons, sometimes abbreviated as "patient autonomy," suggests, as did Justice Cardozo, that "every human being of adult years and sound mind has a right to determine what shall be done with his own body. ''2s Decision-making capacity rather than any disease state or prognosis is the key to making a decision about one's own medical care, even through an advance directive. "Terminal" diseases, therefore, were not discussed anywhere in this statute. This was the only controversial definition influencing the PHAD.

Identification When individuals are hospitalized, they wear an identification band, they are known to the staff who will activate the resuscitation team, and their medical orders are written and accepted through a standard system.

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For EMS personnel the identity of prehospital care patients often is less certain. The more serious the patient's condi- tion or the more confused the setting in which the patient is located, the more difficuh it may be to positively identify the patient. Most EDs recognize this and use coded names and numbers to identify critical patients until a positive identification can be made. Some EMS systems that have adopted successful PHAD protocols, however, have implicitly or explicitly relied on the concept of a "good faith effort" on the part of those in attendance to identify the patient. 19-25

There are several progressively more accurate methods to ensure the patient's identity and be aware of an existing PHAD. The common method is to rely on relatives and friends in attendance with the patient. Alternatively, the patient can wear an identification band signaling that a copy of the PHAD is kept in the hospital record. The PHAD also could be kept within the EMS computer system. There are several ways the actual order may be kept permanently with the patient. It has been suggested that patient identification and PHAD location could be solved if patients wear the Medic Alert ® or a similar medical problem identification system, have a microfilm copy of the PHAD in a tamper-proof container placed subcuta- neously, or, as is done commonly with medication lists and information, keep a copy of their PHAD in an orange tube in the refrigerator.3r What is sought is the simplest safe method of identification that does not stigmatize the patient.

Arizona's option was to rely on a good faith identification effort based on a recent photograph or a written physical description and the corroborating testimony of attending relatives and friends. Some of the major EMS provider agencies testified in public hearings that they thought all patients with PHADs should wear an identification bracelet. The legislation's drafters and the legislators thought that this was excessively onerous and a potential stigma on patients. A uniform orange hospital- type wrist or ankle band was, however, made optional.

Decision-Making Capacity, Witnesses, and Revocation Did the patient (or surrogate) have appropriate decision- making capacity when the PHAD was signed? This is a dilemma because there is little consensus about the components needed to determine decisional capacity. As with most states' general advance directive laws, the Arizona statute assumes that a person (or the surrogate) is competent to make a decision about resuscitation when the document is signed.. A serious ethical question is whether the document was obtained under duress or without informed consent. On inpatient units, it is

unclear how often clinicians implement do-not-attempt- resuscitation orders without full and unbiased disclosure, and it is even less clear what happens outside of the hospital.3S,39 However, it may be impossible to incorporate precautions into PHAD protocols to prevent all types of misuse.4,35

Witnesses are the only legal protection in law against a person fraudulently signing a document. A notary public is only an officially recognized witness. During the legislative process, multiple parties were concerned that someone who could gain financially from a person's death (eg, a provider or owner of health care services) might coerce an incompetent patient or surrogate into signing. a PHAD. Prior Arizona statutes had restricted witnesses to a living will because of these same concerns. In the new statute, persons not eligible to witness advance directives include those named as an agent (surrogate) in an advance directive, those "directly involved with the provision of health care" to the person when the document is completed, or a potential heir related by blood, marriage, or adoption. 15 Yet the witness need not be a notary, so the process is not an onerous burden on the patient.

As situations change, individuals may want to revoke their directive. As with their execution, revoking a directive must be within the ability of patients, who are often incapacitated. Although some PHADs may be difficult to alter, this statute tried to make revocation simple. 4o Under this law, patients can revoke the document by orally notifying a health provider, making a new directive, or performing any act "that demonstrates a specific intent to revoke" the directive, z5

Limitation of Care Options Controversy and possible confusion may stem from the menu of options for treatment offered in PHADs. Some ALS procedures may appear to be prerequisites for others; offering patients multiple ALS options may seem inconsistent with appropriate EMS care or make such care more difficult. However, individuals want the ability to make (albeit sometimes foolish) choices for personal reasons often related to their past experiences. Although the committee writing the draft proposal simplified the options for ALS care, they were expanded by the legislators. Patients have the option of refusing, in any combination, chest compressions, defibrillation, assisted ventilation, intubation, or ALS medications.

Health Treatment Professionals" Involvement How and when should health treatment professionals be involved in a patient's execution of a PHAD? The federal Patient Self-Determination Act implicitly recognized that most physicians have not been explaining advance directives to their patients. 30 In developing the Arizona statute, it


A D V A N C E D I R E C T I V E Iserson

was unclear whether most nonemergency physicians would know enough about the PHAD to be able to explain it to their patients. However, the legislature believed that patients deserved a health treatment professional's explanation that "death might result from any refused care" when ALS procedures were not instituted because EMS personnel complied with the directive. 15 For the PHAD to be valid, a "licensed health professional" is required to sign that this was explained to the patient.

Death Pronouncement Confusion surrounds the question of who can pronounce someone dead outside of a hospital. This often is the cause for inadvertent activation of the EMS system. An obvious and expected home death often will prompt a call to the police "to notify you of a death." These calls inevitably cause immediate transfer to the EMS system for a response. Yet every jurisdiction requires someone to officially pronounce a person dead before a mortician may remove a body from a home. Unless a licensed physician is willing to sign a death certificate, a body cannot be buried or cremated legally. The Arizona PHAD legislation solves both problems. It provides that in the absence of a physician, death can be pronounced by any law enforcement officer, licensed nurse, or state- certified emergency technician. Furthermore, it requires that either the person's personal physician or the medical examiner sign the death certificate.

EMS Provider Levels Virtually all existing PHAD protocols require that within an EMS system, only the highest- level provider (eg, paramedic) may comply with an advance directive and that other EMS providers must perform what ALS measures they are capable of until an ALS provider or physician arrives. Although probably a prudent measure when PHADs were first implemented, this now seems to be an unnecessary use of valuable resources.

EMS providers in Arizona, as in all jurisdictions in the United States, are stratified into many skill levels. As with many states, Arizona is divided into two large metropolitan areas and two medium-size metropolitan areas sepa- rated and surrounded by a vast rural expanse. Relatively few advanced-level EMS providers exist in the rural communities. However, based on the testimony presented to the legislature, rural areas appeared to be in desperate need of a workable PHAD. The only ambulance crew for a large area often would be out of service for several hours while en route to a hospital performing what clearly was futile CPR. Thousands of other citizens then were put at risk if a medical emergency occurred and there could be no timely EMS response. On this basis, the statute speci- fied that all state-certified EMS providers (ambulance-

qualified EMTs through EMT-paramedics) or licensed medical personnel working in the EMS system are permit- ted to withhold treatment on the basis of a patient's PHAD.

Base Station Control and Liability,Potential l iab i l i ty concerns both EMS personnel and hospital-based clinicians who withhold or withdraw treatment based on a patient's PHAD. Statutes can address this problem only by provid- ing specific liability protection, but this is more than most legislatures have been willing to do. 3z As the National Association of EMS Physicians said in a draft document, '~A component of most of the legislation includes a release from liability of those health workers who honor the content of the hiving Will. Unfortunately, it is not clear in all states that EMT/Paramedics are included in the definition of health care worker, thus opening their liability in such cases. "41 However, the Anchorage coroner who supervises their PHAD system stated that " , . . legal risks are easily overplayed...unlikely legal contingencies do not warrant withholding valuable public services. "32

Arizona's PHAD states that ~'emergency medical system and hospital emergency department personnel who make a good faith effort to identify the patient and who rely on an apparently genuine directive are immune from.., crimi- nal and civil liability for that reliance and are not subject to professional discipline. 'uS The law bases the good faith effort only on information known to the provider at the time the PHAD provisions are implemented. 15

The state's health department had concerns about their liability for printing and distributing the PHAD forms, so this job was left to the local hospitals and medical societies.

Use in EDs Extending the use of PHADs into EDs is less of a controversy than a partial solution. Three potential problems are addressed by this extension into the hospital. First, the use of do-not-attempt-resuscitation order s within the ED will be clarified for adult patients lacking decision-making capacity who present with a PHAD. Second, the tardy appearance in the ED of a nonstandard and often unclear advance directive during a resuscitation should be uncommon. Even when this happens, clear and concise PHADs allow withdrawal as well as withholding of care. Last, if EMS personnel are unclear about the situation at the scene, are having difficulty identifying the patient, or are encountering dangerous hostility, they can proceed to the ED, where the emergency physicians will be able to use the PHAD as appropriate.

OUTCOME

The joint committee began drafting their proposed bill in late 1990. The legislative study committee first met in

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A D V A N C E D I R E C T I V E ~TSCtson

October 199l, and its legislator members introduced the bill into the Arizona House of Representatives, where, after several amendments were added that generally improved the structure and substance of the bill, it passed overwhelmingly It then went to the Arizona Senate, where, despite an attempt to add restrictive provisions to other parts of the legislation, it passed easily.

The bill was signed by the governor on June 11, 1992, and became law in late September 1992.

SUMMARY

Few US EMS systems have PHAD protocols, and only four statcwide PHAD statutes exist--although it is an idea whose time has come. Society's imperative to use available technology pushes us to indiscriminately prolong the agony of death by using techniques that initially were designed to save patients with a potential for continuing a meaningful and wanted existence. Our society can no longer tolerate the pain being generated and the resources being lost due to the inability to halt a useless resuscitation in the dying)r

PHAD laws need not be complex in either their language or their implementation requirements. Simple and easily understood statutes and their resulting directives increase the likelihood that those most likely to need and use this directive will be able to comply with its provisions. One area not addressed by the Arizona statute is where the PHAD is to be kept. This was omitted in the recognition that the PHAD will be used in many different sites. Whether this omission will cause confusion is unknown.

Placing a PHAD in statute ensures that a statewide attempt will be made to comply with its provisions, which themselves should be more permanent than advance directive protocols based on administrative fiat. Physicians in other states may want to follow Arizona's lead and use a joint effort by their state's bar association and medical association to smooth the passage of similar legislation. All parties involved, however, must not seek a perfect statute. Arizona's experience suggests that legislators will need to strike a balance between the needs of the citizens and the fears of lawyers wary of any potential liability for the state or the EMS systems.

[Editor's note: Areview of the topic from the perspec- tive of a practicing parainedic and attorney is found in the editorial by RJ Ayers, p. ~748.]

REFERENCES 1. Younger S J: Do-not-resuscitate orders: Na longer secret, but still a problem. Hastings Center Rap 1987;17:24-33.

2. American Heart Association: Textbook of Advanced Cardiac Life Support. Dallas, Texas, AHA, 1987.

3. American Medical Association: Standards and guidelines for cardiopplmonary resuscitation (CPR) and emergency cardiac care (ECC): vii. Medicolegal considerations and recommendations--orders not to resuscitate. JAMA 1980;308:716-717.

4. Ayres R J: Current controversies in prehospital resuscitation of the terminally ill patient. Prehosp Disast &led 1990;5:1:49-57.

5. Biastam M, Ouralde T, Martinez F, at ah Cardiac arrest in the emergency medical service system: guidelines for resuscitation. JAm Cog Emerg Phys 1977;6:525-529.

6. Emergency Medical Services Committee, American College of Emergency Physicians: Guidelines for "do not resuscitate" orders in the prehospital setting (position paper). Dallas, Texas, ACEP, June, 1988.

2. Miles SH, Crimmins T J: Orders to limit emergency treatment for an ambulance in a large metropolitan area. JAMA 1985;254:525-527.

8. Isersen KV, Sanders AB, Mathieu DR, et ah Ethics in Emergency Medicine. Baltimore, Maryland, Williams & Wilkins, 1986, p 105-157.

9. Iserson KV, Rouse F: Prehospital DNR orders. Hastings CenterRep 1989;19:6:17-19.

10. New York Public Health Law 29B, Sect 2960-2979, Chap 370 (1991).

11. State of Montana: HB 635: An Act to Generally Revise the Montana Living Will Act to Conform to the Uniform Rights of the Terminally Ill Act. (enacted April 1991).

12. CoPorado Revised Statutes 15-14-501 through 15-18.6-108, Concerning Patient Autonomy in Regard to the Making of Medical Treatment Decisions (1992).

13. Department of Health Services, Office of Emergency Medical Services, State of Connecticut: "Do Not Resuscitate" Orders in the Pro-Hospital Setting for the Terminally fll Patient. Hartford, CT, Department of Health Services, June 10, 1991.

14. Office of Emergency Medical Services, Department of Human Resources: Guidelines for Out- of-Hospital DO Not Resuscitate Orders in North Carolina. Raleigh, North Carolina, Office of EMS, 1991.

15. Arizona Revised Statute: Living Wills and Health Care Directives Act, Title 36, Chap 32. 1992.

16. Iserson KV: Ethics of emergency medicine. J Emerg Med 1985;3:161.

17. Lee MA. Cassel CK: The ethical and legal framework for the decision not to resuscitate. West J Med1984;140:117-122.

18. Sachs GA, Miles SH, Levin RA: Portable advance directives to limit resuscitation: Emerging policy in the emergency medical system, Ann Intern &led 1991 ;114:151-154.

19. State of Maryland: Hospice/EMS Palliative Care Protocol, passed March 17, 1988.

20. Heenepin County, Minnesota: Directives to Limit Emergency Medical Treatment, November 1984.

21. Kansas City, Missouri: De-Hospital DNR Form, March 1, 1989.

22. Napa County, California: Napa County EMS Do Not Resuscitate Orders, policy No. 90-01- 005/B/14; 3/19/90.

23. Anchorage, Alaska: Memo from D Charlene Doris, Coroner, April 16. 1984.

24. Johnson County, Kansas: Protocol for the Non-Viable, Terminally Ifl, and Do Nat Resuscitate (DNR) Patients, Fall 1989.

25. Juneau, Alaska: EMS Do Not Resuscitate Protocol, 1990.

26. Cruzan vHarmon, 760 SW2d 408, at 419-424 (Me bane 19881.

27. Cruzan vDirector, Missouri Department of Health, 110 S Ct 2841 {1990).

28. SchloendorffvSecietyofNew York Hospital, 211 NY 125, 129, 105 NE £2 (1914).

29. Ethics Committee, American College of Emergency Physicians Ethics Committee: American College of Emergency Physicians ethics manual. Ann Emerg Mad 1991;20:1153-1162.

39. Omnibus Budget Reconciliation Act of 1990; Public Law 101-508, Sect 4751.

31. Annas G J: CPR: The beat goes on. Hastings CenterRep 1982;12:24-25.

32. Marshall L: Resuscitating the terminally ill. J Emerg &led Sen/1985;Apdh24-28.

33. Arizona Revised Statute: Arizona Medical Decisions Treatment Act, Title 36, Chap 32 {1985).


ADVANCE DIRECTIVE Ise~o~

34. Arizona Revised Statute: Title 36, Chap 32 (1991).

35. Cdmmins T J: The need for a prehospital DNR system. Prehosp Disast Med 1990;5:1:47-49.

36. American College of Emergency Physicians: Guidelh3es for "do-not-resuscitate" orders in the prehespital setting. Ann Emerg Med 1988;17:1106-1108.

37. Iserson KV: Foregoing prehospital care: Should ambulance staff always resuscitate? J Med Ethics1991;17:19-24.

38. President's Commission for the Study of Ethical Problems in Medicine and Biomedical end Behavioral Research: Deciding to Forego Life-Sustaining Treatment: A Report on the Ethical Medical, and Legal lssues in Treatment Decisions. Washington, DC, US Government Printing Office, 1983.

39. Bedell SE, Delbance TL: Choices about cardiopulmonary resuscitation in the hospital: When do physicians talk with patients? N Engl J Med 1984;309:1089.

40. Iserson KV: The 'no code' tattoo: An ethical dilemma. West J IVied 1992;156:309-312.

41. NationaT Association of Emergency Medical Services Physicians: Consensus document on resuscitation decisions in the prehospital setting. Special bulletin, NAEMSP, 1989.

Address for reprints:

Kenneth V Iserson, MD, MBA, FACEP

Section of Emergency Medicine

University of Arizona College of Medicine ,

1501 North Campbell Avenue

Tucson, Arizona 85724

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a simplified prehospital advance directive law: arizona's approach

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