State Of Arizona Living Will Form printable pdf download

STATE OF ARIZONA

LIVING WILL (End of Life Care)

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.

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

My Name:

My Age:

My Address:

My Date of Birth:

My Telephone:

2. 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:

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State Of Arizona Living Will Form