State Of Arizona Living Will (End Of Life Care) Page 7
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9indicate which organs or tissues you want to donate and where you want them donated.
Initial or put a check mark by A or B below. If you select B, continue with your choices.
A. I DO NOT WANT to make an organ or tissue donation, and I do not want this
donation authorized on my behalf by my representative or my family.
B. I DO WANT to make an organ or tissue donation when I die. Here are my
directions:
1. What organs/tissues I choose to donate: (Select a or b below)
a. Any needed organ or parts.
b. These parts or organs:
2. What purposes I donate organs/tissues for: (Select a, b, or c below)
a. Any legally authorized purpose (transplantation, therapy, medical and dental
evaluation and research, and/or advancement of medical and dental science).
b. Transplant or therapeutic purposes only.
c. Other:
3. What organization or person I want my parts or organs to go to:
a. I have already signed a written agreement or donor card regarding organ and
tissue donation with the following individual or institution: (Name)
b. I would like my tissues or organs to go to the following individual or
institution: (Name)
c. I authorize my representative to make this decision.
7. About a Living Will:
NOTE: If you have a Living Will and a Durable Health Care Power of Attorney, you
must attach the Living Will to this form. A Living Will is available on the Attorney
General (AG) web site. Initial or put a check mark by box A or B.
A. I have SIGNED AND ATTACHED a completed Living Will in addition to this
Durable Health Care Power of Attorney to state decisions I have made about end of life
health care if I am unable to communicate or make my own decisions at that time.
B. I have NOT SIGNED a Living Will.
8. About a Prehospital Medical Care Directive or Do Not Resuscitate Directive:
NOTE: A form for the Prehospital Medical Care Directive or Do Not Resuscitate
Directive is available on the AG web site. Initial or put a check mark by box A or B.
A. I and my doctor or health care provider HAVE SIGNED a Prehospital
Medical Care Directive or Do Not Resuscitate Directive on paper with ORANGE
background in the event that 911 or Emergency Medical Technicians or hospital
emergency personnel are called and my heart or breathing has stopped.
B. I have NOT SIGNED a Prehospital Medical Care Directive or Do Not
Resuscitate Directive.
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