Arizona Living Will Form

Through the fulfillment of this form, an Arizona-based individual can declare the end-of-life treatments s/he wishes to receive should s/he come to a deteriorated mental state at a later time.

Extracted Text for Proper Search

_______________________________________________________________________________________________________________________________ 
Developed by the Office of the Attorney General                                                                        Updated Jan uary 18, 2011 
TOM HORNE                                                                   (All  documents completed before January 18, 2011 are still valid) 
www.azag.gov	
                          LIVING WILL 	
Page 1 of 2 
 
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 v egetative state or an irreversible coma. You should  talk to your doctor about what these terms 
mean. The Living Will states what choices y ou 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 su ch 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 furt her 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 ch oices 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 in itial 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 carefull y 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 l ive 
birth with the continued applicat ion 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 necess ary to treat my condition until my doctors reasonably conclude th at 
my condition is terminal or is irreversible and in curable, 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 Jan uary 18, 2011 
TOM HORNE                                                                   (All  documents completed before January 18, 2011 are still valid) 
www.azag.gov	
                          LIVING WILL 	
Page 2 of 2 
 	
3. Other Statements Or Wishes I Want Followed For End of Life Care:   
NOTE:  You can attach additional provisions or lim itations on medical care that have not been included in this Living Will form. 
Initial or put a check mark by box A or B below.  Be sure to include the attachment if you check B.  
_______ A. I have not attached additional special provisions or limitations about End of Life Care I want.  
_______ B.  I have attached additional special provisions or  limitations about End of Life Care I want.  
SIGNATURE OR VERIFICATION  
A.  I am signing this Living Will as follows: 
My Signature: ___________________________________________________  Date: _____________________________               
B.  I am physically unable to sign this Living Will, so a witness is verifying my desires as follows:  
Witness Verification:  I believe that this Living Will accurately expresses the wishes communicated to me by the principal of 
this document. He/she intends to adopt this Living Will at this  time. He/she is physically unable to sign or mark this document  
at this time. I verify that he/she directly indicated to me t hat the Living Will expresses his/her wishes and that he/she intends to 
adopt the Living Will at this time.  
Witness Name (printed): ________________________________________________________________________________ 
Signature: _______________________________________________________      Date: _____________________________ 
SIGNATURE OF WITNESS OR NOTARY PUBLIC   
NOTE:    At least one adult witness OR a Notary Public must wi tness you signing this document and then sign it.  The witness 
or Notary Public CANNOT be anyone who is: (a) under the age of 18 ; (b) related to you by blood, adoption, or marriage; (c) 
entitled to any part of your estate; (d) appointed as your representative; or (e) involved in providing your health care at the  time 
this document is signed.  
A. Witness:   I certify that I witnessed the signing of this docum ent by the Principal. The person who signed this Living Will 
appeared to be of sound mind and under no pressure to ma ke specific choices or sign the document. I understand the 
requirements of being a witness.  I confirm the following:  
♦I am not currently designated to make medical decisions for this person. 
♦ I am not directly involved in administering health care to this person.  
♦ I am not entitled to any portion of this person’s estate upon his or her death under a will or by operation of law.  
♦ I am not related to this person by blood, marriage, or adoption. 
 
          Witness Name (printed): ___________________________________________________________________________ 
          Signature: __________________________________________________________   Date: ______________________  
          Address: ________________________________________________________________________________________ 
B. Notary Public:  (NOTE: a Notary Public is only required if no witness signed above)  
STATE OF ARIZONA                                             ) ss  
COUNTY OF____________________________  )  
The undersigned, being a Notary Public certified in Arizona, dec lares that the person making this Living Will has dated and signed or marked it 
in my presence, and appears to me to be of sound mind and free from duress.  I further declare I am not related to the person s igning above, by 
blood, marriage or adoption, or a person desi gnated to make medical decisions on his/her behalf.  I am not directly involved in providing health 
care to the person signing.  I am not entitled to any part of  his/her estate under a will now existing or by  operation of law.  In the event the 
person acknowledging this Living Will is phy sically unable to sign or mark this document, I verify that he/she directly indicated to me that the 
Living Will expresses his/her wishes and that he/she  intends to adopt the Living Will at this time.  
WITNESS MY HAND AND SEAL this _______ day of  ____________________, 20____.  
Notary Public: ________________________________________________  My commission expires: _____________________