Arizona Living Will Form

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An Arizona living will is a directive that instructs medical staff on a person’s end-of-life care preferences. A living will is only used when a patient is considered terminally ill and is not able to speak for themselves. The form directs medical staff to provide or withdraw life-sustaining procedures such as feeding and breathing assistance.

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Article 1 My Information

(1) Arizona Principal Name. It will be assumed the Arizona Patient setting his or her medical instructions to paper through this document will be doing so directly. Thus, if you are the Arizona Patient attach your full name to the “My Information” section where it is requested then continue to provide some supporting information and the details needed to contact you. If you are preparing this document, then record the Arizona Patient’s information to this section so that he or she can be properly named as the Principal issuing this paperwork.

(2) Age And Date Of Birth.

(3) Address And Phone Number Of Arizona Declarant.

Article 2 My Decisions About End Of Life Care

Select Statements A, B, C, And/or D Or Statement E

(4) Comfort Care Only. The Arizona Principal behind this document should determine the level of Arizona medical care he or she expects and approves of when he or she has been incapacitated and unable to communicate while suffering a fatal disease, medical condition, or declared to be in a long-term to permanent coma (unconscious) where the hope of recovery is nearly non-existent. If the Arizona Principal approves of medical care provided so long as it does not prolong life and maintains his or her comfort, then Statement A must be initialed to present this instruction to attending Arizona Medical Doctors.

(5) Specific Limitations On Medical Treatment. This directive can be set to combine the benefits of comfort care with the prolonging of life through Statement B. Initial this statement to approve of receiving medical treatment while denying unwanted procedures. Three additional statements (numbered 1 to 3) allows the Arizona Principal to deny specific care that is administered as a standard response to the Arizona Principal’s condition. Statement 1 enables the Arizona Principal to refuse all forms of CPR once it is initialed, Statement 2 can be used to deny artificially delivered food and fluids (i.e., water), and Statement 3 should be initialed if the Arizona Principal does not want to be hospitalized unless it is absolutely necessary to maintain his or her comfort and pain levels.

(6) Pregnancy. If the Arizona Principal is still in childbearing years, then she may wish to issue a directive regarding pregnancy. Statement C should be initialed if the Arizona Principal wishes to declare that if she is pregnant when rendered incapacitated with a terminal medical condition or permanent unconsciousness, but the embryo can survive to full term, then all directives instructing that life-sustaining treatment be withheld are suspended until the birth of the child.

(7) Treatment Until My Medical Condition Is Reasonably Known. Some medical conditions can be very complicated thus making the reason for the Arizona Principal’s incapacitation unknown even if he or she has a pre-existing terminal condition (i.e., cancer, leukemia, etc.). If the Arizona Principal wishes to receive all available medical care while the cause of his or her incapacitation is unknown, then Statement D must be initialed.

(8) Direction To Prolong My Life. The Arizona Principal can direct that all life-prolonging procedures available be used as necessary to extend his or her life through Statement E’s language. If this statement is initialed, then the statements above it should not be.

Article 3 Other Statements Or Wishes I Want Followed For End Of Life Care

(9) Additional Statements. One of two statements in this section should be check marked. This will inform Arizona Doctors reviewing this document on whether they should seek an attachment containing additional health care authorizations, refusals, and/or instructions. If the Arizona Principal does not have additional instructions, then Statement A should be selected. If an attachment containing additional Arizona Principal health care instructions will be attached, then select Statement B (and make sure the concerned attachment is present by the time this document is executed by the Arizona Principal).Signature Verification.

(10) Arizona Principal’s Signature. The Arizona Principal’s signature must be presented on this document before two Witnesses or a Notary Public even if this act must be performed by the Arizona Principal’s.

(11) Signature Date Of Arizona Declarant.

(12) Proxy Name (Printed). If the Arizona Principal lacks the ability to issue this document but has provided a Proxy the ability to sign it on his or her behalf, then this Arizona Proxy must be identified. It must be noted that a Signature Proxy for the Arizona Principal cannot also act as a Witness to this document’s signing. The Proxy must print his or her name to identify himself or herself as such where requested.

(13) Proxy Signature. The Arizona Principal’s Proxy must sign his or her own name directly below the signature provided.

(14) Date Of Proxy Signature.

Witness

(15) Witness Name (Printed). The acting Witness will only qualify for this role if he or she is not a Health Care Agent of the Principal in any way, shape, or form, is not responsible for the Principal’s health care, is not eligible for any part of the Arizona Principal’s estate upon the Principal’s death, and is not a blood relation, spousal relation, or related by adoption to the Arizona Principal. If these qualifications are met, then the Witness may watch the Arizona Principal (or Proxy) sign this document. To testify this signature was provided with full knowledge of the results then the Witness should print his or her name at the introduction of the signature area provided.

(16) Witness Signature. The Arizona Principal’s Witness must sign this document to demonstrate that he or she will testify that the Principal’s signature was fairly and authentically produced. 

(17) Witness Signature Date. The calendar date when the Witness’s signature was made should be documented.

(18) Witness Address. The mailing address of the Arizona Principal’s Witness must also be provided.

Notarial Jurat

(19) Notarization Of Arizona Declarant’s Signature. If the Arizona Principal’s signature will be notarized to prove its authenticity, then, the final section of this directive will be used by the attending Notary Public for the notarization process.