Living Will (End of Life Care)
LIVING WILL — ARIZONA Any writing that meets the requirements of A.R.S. Title 36, Article 4 may be used to create a living will. This document is a standalone living will. It does not create a health-care power of attorney. Name: the information supplied in the interview Address: the information supplied in the interview Some general statements concerning health-care options are outlined below. Paragraphs 1, 2, 3, and 4 may be initialed in any combination. If paragraph 5 is initialed, paragraphs 1 through 4 must not be initialed. the information supplied in the interview 1. Terminal condition — do not prolong dying If I have a terminal condition I do not want my life to be prolonged and I do not want life-sustaining treatment, beyond comfort care, that would serve only to artificially delay the moment of my death. the information supplied in the interview the information supplied in the interview 2. Comfort care with specific limits If I am in a terminal condition or an irreversible coma or a persistent vegetative state that my doctors reasonably feel to be irreversible or incurable, I do want the medical treatment necessary to provide care that would keep me comfortable, but I do not want the following: the information supplied in the interview(a) Cardiopulmonary resuscitation, for example, the use of drugs, electric shock and artificial breathing.the information supplied in the interview the information supplied in the interview(b) Artificially administered food and fluids.the information supplied in the interview the information supplied in the interview(c) To be taken to a hospital if at all avoidable.the information supplied in the interview the information supplied in the interview the information supplied in the interview 3. Pregnancy election Notwithstanding my other directions, if I am known to be pregnant, I do not want life-sustaining treatment withheld or withdrawn if it is possible that the embryo/fetus will develop to the point of live birth with the continued application of life-sustaining treatment. the information supplied in the interview the information supplied in the interview 4. Treatment until the statutory trigger Notwithstanding my other directions I do want the use of all medical care necessary to treat my condition until my doctors reasonably conclude that my condition is terminal or is irreversible and incurable or I am in a persistent vegetative state. the information supplied in the interview the information supplied in the interview 5. Maximum life prolongation I want my life to be prolonged to the greatest extent possible. the information supplied in the interview Other or additional statements of desires the information supplied in the interviewI have not attached additional special provisions or limitations to this document to be honored in the absence of my being able to give health care directions.the information supplied in the interview the information supplied in the interviewI have attached additional special provisions or limitations to this document to be honored in the absence of my being able to give health care directions: the information supplied in the interview the information supplied in the interview Signature If this living will is not part of a health-care power of attorney, A.R.S. § 36-3261 requires verification in the same manner as § 36-3221: dated and signed, then either notarized or witnessed in writing by at least one adult. Use one route, not both. Principal signature: Date: the information supplied in the interview If the principal is physically unable to sign or mark, the notary or each witness shall verify that the principal directly indicated that this living will expressed the principal's wishes and that the principal intended to adopt it at that time. Witness / notary verification if signing for the principal: Witness route Use this route only if a notary does not sign. If only one witness signs, that witness may not be related to the principal by blood, marriage, or adoption and may not be entitled to any part of the principal's estate. A witness may not be a person designated to make medical decisions on the principal's behalf or a person then directly involved in providing the principal's health care. Witness signature: Print name / address: Date: OR — Notary route Use this route only if a witness does not sign. Notary Public: Commission expires: This Living Will is not an Arizona Prehospital Medical Care Directive (DNR) or POLST medical order.