Q.  What are advance directives?

A.  Advance directives are legal documents that outline what healthcare and treatment decisions should be made if you are unable to communicate these wishes. In Arizona, there are three types of documents that fall under this category: 1. Living Will 2. Health Care Power of Attorney 3. Mental Health Care Power of Attorney 4. Pre-hospital Medical Care Directive 

Q.  What is a living will? 

A.  A living will is a legal document that outlines in writing your wishes regarding medical treatment in the event you are not able to communicate this directly with your healthcare providers. Your living will can also help guide your designated health care power of attorney (if you have elected one). 

Q.  I do not have a mental illness, so why would I need a mental health care power of attorney? 

A.  A mental health care power of attorney (MPOA) in Arizona will allow your chosen agent to make decisions for you regarding behavioral health placement and mental health treatment if you no longer have capacity to do so due to mental or physical illness. This can occur for reasons outside a mental illness, such as dementia, Alzheimer’s disease or even a medication interaction. It is an important document to consider as part of your advance care planning. 

Q.  What can my health care power of attorney (HCPOA) do? 

A.  Your HCPOA can make medical decisions if you are not able to make them for yourself. The HCPOA can discuss treatment options with your doctor and decide on the course of treatment. Your HCPOA only goes into effect when your physician states that you are incapacitated, or you are unable to speak for yourself. Additionally, you can revoke or change your document at any time prior. 

Q.  Who should I choose for my agent/proxy? 

A.  It is imperative to choose someone you trust (who is over the age of 18), and feel will be comfortable carrying out and communicating your wishes. Another factor to consider is how available this person will be to your healthcare team. It is crucial you have a conversation with the individual you are choosing, before finalizing the documents, so together you can discuss his/her role as your agent, along with your treatment and care choices. If you have not legally documented your choice for a healthcare agent, in an emergency the healthcare team will turn to your legal next of kin (AZ Surrogate Decision Maker Law), who may not be the person you would have wanted to represent you. Your closest friend or significant other will not be among your legal next of kin and would not have any say in your care unless they are designated on the legal health care power of attorney document. 

Q.  Isn’t it better to have more than one healthcare agent/proxy? 

A.  Experts recommend you name one person to make the decisions and then have an alternate if that person cannot communicate your healthcare decisions. If you name two people, they may disagree, which can make them ineffective advocates for your choices and confuse or slow down the process, making it possible that your decisions are not honored. 

Q.  Advance care planning is only for sick or elderly people, right? 

A.  You cannot predict how and when you will become seriously ill or injured. COVID-19 has been a difficult reminder that young, healthy people can have their health circumstances change in an instant. While your health care and power of attorney choices will likely change over time, you can amend your documents as often as you wish. All people over the age of 18 should complete some advance care planning. 

Q.  What if I change my mind? 

A.  We all experience changes throughout our lifetime. Changes in relationships, where we live and changes in our health status. Consider reviewing and updating your advance care planning documents regularly to be sure they still reflect your wishes. People should use the “5 Ds” to remind us when to review our advance directives: Death, Divorce (or change in relationship status), Decline, Diagnosis and Decade. After updating your documents, destroy all previous copies. Notify your health care power of attorney, family and healthcare team of the changes and provide them with the updated forms. To keep track of who has these documents, you can list who has a copy on the back of your original document. 

Q.  Do I need an attorney to complete an advance directive? 

A.  No, you do not need an attorney to complete your advance directives in Arizona. The forms are available for free on several websites and many resources exist to assist you should you have questions. You can speak with your healthcare team, social service case manager or a member of the clergy in your faith community about completing advance directive. If you are working with an attorney to complete an estate plan, they can also assist you with completing these documents. 

Q.  My family knows my wishes, so why do I have to write them down? 

A.  While thinking about and planning for what you would want when your health status becomes critical can be difficult, documenting these wishes can ensure that your choices are honored if you are not able to communicate them. Putting them in writing provides clear instructions and gives your family peace of mind that they are representing your choices accurately. These documents also minimize the chance that family members will disagree about what choices to make, which can have a future impact on relationships. 

Q.  What is a POLST? 

A.  Portable medical orders for those who are seriously ill. POLST is a part of advance care planning and is more specific than a living will. It is a process that includes a conversation with a provider about your medical condition and treatment options you want when you are seriously ill. While a living will is for future care, a POLST form is for current care. POLST is a medical form that travels with you in any care setting, including your home. POLST is a document signed by you and your physician, a nurse practitioner or physician assistant. (azhha.org/Arizona_polst) 

Q.  What is a pre-hospital medical care directive (DNR – Do Not Resuscitate)? 

A.  A pre-hospital medical care directive is a document signed by you and your licensed healthcare provider 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 other medical interventions that are necessary to provide comfort care or to alleviate pain. 

Q.  Do advance directives documents need to be notarized? 

A.  The durable health care power of attorney, living will and durable mental health care power of attorney must be signed by EITHER a witness OR a notary. Please note that the witness must be at least 18 years of age, cannot be family (related by blood, adoption or marriage), cannot be in your will to receive part of your estate, cannot be appointed as your representative and cannot be one of your healthcare providers. 

Advance Care Planning - Planning for healthcare you want to receive if you are facing a medical crisis. These are your decisions to make based on your personal values, preferences and discussions with your loved ones. If under the care of a physician, you should consult him/her also.

Advance Directive - A document drafted according to Arizona law that outlines your wishes regarding your healthcare and treatment. These documents are only valid when you are no longer capable of making or communicating your own decisions. There are several documents that are listed as advance directives according to A.R.S. §36-32 in the state of Arizona, including:

1. Living Will 

2. Health Care Power of Attorney 

3. Mental Health Care Power of Attorney 

4. Pre-hospital Medical Care Directive – Do Not Resuscitate (DNR) 

Agent - An individual (over the age of 18) who has been chosen to make healthcare treatment decisions for a person at the time he/she is unable to make these decisions due to incapacity or inability to communicate. 

Artificial Nutrition or Hydration - A medical treatment when a patient is no longer able to take in nutrition (food) or hydration (fluids) by mouth. Can be done through a tube either through the nose into the stomach or through the skin into the stomach. 

Attending Physician - A physician (doctor) who has the primary responsibility for a patient’s healthcare. 

Cardiopulmonary Resuscitation (CPR) - Cardiopulmonary resuscitation is a group of treatments used when someone’s heart and/or breathing stops. CPR is performed in an attempt to restart the heart and breathing. It may consist only of mouth-to-mouth breathing, or it can include pressing on the chest to mimic the heart’s function and cause blood to circulate. Electric shock and drugs also are used frequently to stimulate the heart. 

Comfort Care - A patient care plan that is focused on symptom control, pain relief and quality of life. 

Decision-Making Capacity - In relation to end-of-life decision-making, a patient has medical decision-making capacity if he/she has the ability to understand the medical problem and the risks and benefits of the available treatment options. The patient’s ability to understand other, unrelated concepts is not relevant. The term is frequently used interchangeably with “competency” but it is not the same. Competency is a legal status imposed by the court. 

Do Not Resuscitate (DNR) - Do Not Resuscitate order (also referred to as a No Code or Allow Natural Death) is a physician’s written order instructing healthcare providers not to attempt cardiopulmonary resuscitation (CPR) in case of cardiac or respiratory arrest. A person with a valid DNR order will not be given CPR under these circumstances. Although the DNR order is written at the request of a person or his/her family, it must be signed by a physician to be valid. In Arizona, a non-hospital DNR order is written for individuals who are at home and do not want to receive CPR. This is called a pre-hospital medical care directive. It must be on orange paper. A DNR order does not mean you will not receive all comfort measures. 

Emergency Medical Services (EMS) - A group of governmental and private agencies that provide emergency care, usually to persons outside healthcare facilities. EMS personnel generally include paramedics, first responders and other ambulance crew. 

Health Care Power of Attorney (Durable Power of Attorney for Healthcare) - A legal document that lets you choose another person, called an "agent," to make healthcare decisions if you can no longer make those decisions for yourself. Unless the document includes specific limits, the agent will have broad authority to make any healthcare decision you could normally make for yourself. Health care power of attorney documents do not provide for any financial decision-making powers. The person appointed may be called a healthcare agent, representative, surrogate, attorney-in-fact or proxy. 

HIPAA - Health Insurance Portability and Accountability Act (HIPAA) is a federal law that created national standards to protect personally identifiable patient health information from being disclosed without the patient’s consent or knowledge. 

Hospice - A type of healthcare that can be offered in any setting that focuses on comfort and symptom management versus life-prolonging treatment. Hospice providers often work as a team of staff that often includes registered nurses, social worker, chaplains and/or volunteers. Patients receiving hospice services are no longer receiving treatment for their advanced illness. 

Hospitalist - A physician whose practice focuses on patients who are admitted into the hospital and does not follow them back into the community or clinic setting.

Incapacitation - A person is said to be incapacitated if he/she is unable to function in a particular way (or not at all) because of severe illness, dementia or unconsciousness.

Intubation - Refers to "endotracheal intubation," the insertion of a tube through the mouth or nose into the trachea (windpipe) to create and maintain an open airway to assist breathing. 

Life-sustaining Treatment - Medical treatment that is meant to sustain or prolong one’s life. It may provide life-lengthening but often is not curative. Examples may include, but are not limited to, dialysis, CPR, ventilation, surgery. 

Living Will - A living will is a legal document that outlines in writing your wishes regarding medical treatment in the event you are not able to communicate this directly with your healthcare providers. It can also help guide your designated health care power of attorney (if you have elected one). 

Mental Health Care Power of Attorney - A document that allows and directs your chosen agent to make decisions for you regarding behavioral health placement and treatment if you no longer have capacity to do so yourself due to mental or physical illness. This can occur because of dementia or medication interactions or a mental health diagnosis. It is a healthcare document to consider as part of your advance care planning. 

Palliative Care - Palliative care is a medical caregiving approach aimed at optimizing quality of life and alleviating suffering among people with serious, complex illness. This approach can include a combination of medical, faith-based and family-based practices. Patients who receive palliative care services may still be actively pursuing treatment options for their advanced illness. 

Persistent Vegetative State - A condition in which a medical patient is completely unresponsive to psychological and physical stimuli and displays no sign of higher brain function, is not expected to improve and is being kept alive only by medical intervention. 

Pre-hospital Medical Care Directive - A pre-hospital medical care directive is a document signed by you and a licensed healthcare professional that informs emergency medical technicians (EMTs) or hospital emergency personnel not to resuscitate you. This is also referred to as 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 other medical interventions that are necessary to provide comfort care or to alleviate pain. In Arizona, this document needs to be printed on orange paper. (azag.gov) 

Principal - The person about whom an advance directive is written. 

POLST - A POLST form helps individuals who are considered to be at risk for a life-threatening clinical event because they have a serious life-limiting medical condition, which may include advanced frailty, for whom their healthcare professional wouldn’t be surprised if they died within 1-2 years, communicate their treatment decisions. It is designed to improve patient care by creating a portable medical order form (the POLST form) that records patients’ treatment wishes so emergency personnel know what treatments the patient wants in the event of a medical emergency.

The current standard of care during an emergency is for emergency medical services (EMS) to attempt everything possible to attempt to save a life. Not all patients who are seriously ill want this treatment and the POLST Paradigm provides the option for them to: (1) confirm this is the treatment they want or (2) to state what level of treatment they do want. POLST is always voluntary. Because it is a medical order it helps give patients more control over receiving treatments they do want to receive and avoid treatments they do not want to receive, even if they cannot speak for themselves during a medical crisis. (azhha.org/Arizona_polst) 

Respiratory Arrest - The cessation of breathing; an event in which an individual stops breathing. If breathing is not restored, an individual's heart will eventually stop beating, resulting in cardiac arrest.

Revoke - A formal way to cancel your present advance directive documents.

Surrogate - A surrogate is someone who may make decisions about healthcare treatment on behalf of a patient who is found incapable. The surrogate may have been designated by the patient in a completed health care power of attorney document, appointed by the court as a guardian or as indicated by state statute in the following order of priority: 

1. Patient’s spouse; 

2. An adult child (or if more than one adult child, consent of the majority); 

3. A parent of the patient; 

4. A brother or sister; 

5. A close friend (one who has exhibited special care and concern) Terminal Condition An infection or disease that is life-limiting, incurable and ultimately fatal. It is possible for people to live several years with a terminal condition. Ventilator A machine that provides mechanical ventilation by moving breathable air into and out of the lungs, to deliver breaths to a patient who is physically unable to breathe or breathing insufficiently. 

Have a Say in Advance Care Planning - AZ 4.2021 (English version)

Tener voz y voto en la planificación de la atención previa. AZ 4.2021 (Spanish version)