Fillable Living Will (End Of Life Care) Form - Arizona printable pdf download

STATE OF ARIZONA

LIVING WILL (End of Life Care)

Instructions and Form

GENERAL INSTRUCTIONS: Use this Living Will form to make decisions now about your medical care if you are ever in a

terminal condition, a persistent vegetative state or an irreversible coma. You should talk to your doctor about what these terms

mean. The Living Will states what choices you would have made for yourself if you were able to communicate. It is your written

directions to your health care representative if you have one, your family, your physician, and any other person who might be

in a position to make medical care decisions for you. Talk to your family members, friends, and others you trust about your

choices. Also, it is a good idea to talk with professionals such as your doctor, clergyperson and a lawyer before you complete

and sign this Living Will.

If you decide this is the form you want to use, complete the form. Do not sign the Living Will until your witness or a Notary

Public is present to watch you sign it. There are further instructions for you about signing on page 2.

IMPORTANT: If you have a Living Will and a Durable Health Care Power of Attorney, you must attach the Living Will

to the Durable Health Care Power of Attorney.

Information about me: (I am called the “Principal”)

My Name: __________________________________________

My Age: _________________________________

My Address:_________________________________________

My Date of Birth: ___________________________

___________________________________________________

My Telephone: ____________________________

My decisions about End of Life Care:

NOTE: Here are some general statements about choices you have as to health care you want at the end of your life. They are

listed in the order provided by Arizona law. You can initial any combination of paragraphs A, B, C, and D. If you initial

Paragraph E, do not initial any other paragraphs. Read all of the statements carefully before initialing to indicate your

choice. You can also write your own statement concerning life-sustaining treatments and other matters relating to your health

care at Section 3 of this form.

______ A.

Comfort Care Only: 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. (NOTE: “Comfort

care” means treatment in an attempt to protect and enhance the quality of life without artificially prolonging life.)

______ B.

Specific Limitations on Medical Treatments I Want: (NOTE: Initial or mark one or more choices, talk to your

doctor about your choices.) If I have a terminal condition, or am in an irreversible coma or a persistent vegetative state that my

doctors reasonably believe 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:

____

1.) Cardiopulmonary resuscitation, for example, the use of drugs, electric shock, and artificial breathing.

_____ 2.) Artificially administered food and fluids.

_____ 3.) To be taken to a hospital if it is at all avoidable.

_______ C. Pregnancy: Regardless of any other directions I have given in this Living Will, 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.

_______ D. Treatment Until My Medical Condition is Reasonably Known: Regardless of the directions I have made in

this Living Will, 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.

_______ E. Direction to Prolong My Life: I want my life to be prolonged to the greatest extent possible

STATE OF ARIZONA LIVING WILL (“End of Life Care”) (Cont’d)

_______________________________________________________________________________________________________________________________

Developed by the Office of the Attorney General

Updated January 18, 2011

TOM HORNE

(All documents completed before January 18, 2011 are still valid)

LIVING WILL

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Living Will (End Of Life Care) Form - Arizona

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