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ARIZONA

Advance Directive

Planning for Important Health Care Decisions

Caring

nfo

1731 King St., Suite 100,

Alexandria,

VA 22314

www.caringinfo.org

800/658-8898

CARINGINFO

Caringinfo, a program of the National Hospice and Palliative Care Organization (NHPCO), is a

national consumer engagement initiative to improve care at the end of life.

It’s About How You LIVE

It’s

About

How You LIVE is a national community engagement campaign encouraging

individuals to make informed decisions about end-of-life care and services. The campaign

encourages people to:

Learn about options for end-of-life services and care

Implement plans to ensure wishes are honored

Voice decisions to family, friends and health care providers

Engage in personal or community efforts to improve end-of-life care

Note: The following is not a substitute for legal advice. While Caringinfo updates the following

information and form to keep them up-to-date, changes in the underlying law can affect how the

form will operate in the event you lose the ability to make decisions for yourself. If you have any

questions about how the form will help ensure your wishes are carried out, or if your wishes do

not seem to fit with the form, you may wish to talk to your health care provider or an attorney

with experience in drafting advance directives. If you have other questions regarding these

documents, we recommend contacting

your state attorney general's office.

Reproduction and distribution by an organization or organized group without the written permission of

the National Hospice and Palliative Care Organization is expressly forbidden.

Using these Materials

BEFORE YOU BEGIN

1. Check to be sure that you have the materials for each state in which you may

receive health care.

2. These materials include:

•

Instructions for preparing your advance directive, please read all the

instructions.

•

Your state-specific advance directive forms, which are the pages with the

gray instruction bar on the left side.

ACTION STEPS

1. You may want to photocopy or print a second set of these forms before you start so

you will have a clean copy if you need to start over.

2. When you begin to fill out the forms, refer to the gray instruction bars — they will

guide you through the process.

3. Talk with your family, friends, and physicians about your advance directive. Be sure

the person you appoint to make decisions on your behalf understands your wishes.

4. Once the form is completed and signed, photocopy the form and give it to the

person you have appointed to make decisions on your behalf, your family, friends,

health care providers and/or faith leaders so that the form is available in the event

of an emergency.

5. Arizona maintains an Advance Directive Registry. By filing your advance directive

with the registry, your health care provider and loved ones may be able to find a

copy of your directive in the event you are unable to provide one. You can read

more about the registry, including instructions on how to file your advance directive,

at https://www.azsos.gov/adv_dir/.

6. You may also want to save a copy of your form in an online personal health records

application, program, or service that allows you to share your medical documents

with your physicians, family, and others who you want to take an active role in your

advance care planning.

Introduction to Your Arizona Health Care Directive

This packet contains the

Arizona Advance Health

Care

Directive,

which protects your

right to refuse medical treatment you do not want or to request treatment you do want

in the event you lose the ability to make decisions yourself.

The first part of this document is a

Health

Care

Power

Attorney

that permits the

appointment of an adult as Agent. This section lets you name an adult agent to make

decisions about your medical care, including decisions about life-sustaining treatment, if

you can no longer speak for yourself.

The second part of this document is a Living Will. It lets you discuss your wishes about

medical care in the event that you develop a terminal condition or are permanently

unconscious and can no longer make your own medical decisions. Your living will may

control or guide your agent's decisions regarding your health care treatment.

The third part of this document records your wishes regarding an autopsy not required

by law. Under certain circumstances, Arizona law will require an autopsy, regardless of

your wishes.

The fourth part of this document allows you to make a donation of your organs or to

refuse to allow your organs to be used following your death.

The fifth part of this document is a

Physician

Affidavit. You may wish to ask questions

of your physician regarding your end-of-life decisions. If so, it is a good idea to ask

your physician to complete the affidavit and keep a copy for his or her file.

The sixth part of this document allows you to record your choices regarding your

funeral and burial decisions.

Your

Arizona Health

Care

Directive

goes into effect when your doctor determines that

you are no longer able to make or communicate your health care decisions.

This form does not contain a

Mental Health

Care

Power

of Attorney. The Arizona

Attorney General’s office provides more information on these documents, including a

form and instructions, at http://www.azag.gov/life_care/index.html. However, if you do

not have a mental health care power of attorney, your general health care power of

attorney may make decisions about mental health treatment on your behalf if you are

found to be incapable of making decisions,

except

that your agent cannot consent to

your admission at an inpatient psychiatric facility unless expressly authorized to do so.

Note: This

document

will be legally

binding

only if the

person completing

the document

is a

competent

adult who is at least 18 years of age.

Instructions for Completing Your Arizona Health Care Directive

How do I make my

A riz o n

a H e alt h C are D i r ect i v e legal?

The law requires that you sign and date your Arizona Health Care Directive in the

presence of at least one (1) adult witness.

You can do this in either of two ways:

1. Sign and date your document in the presence of at least one witness, who must also

sign the document and affirm that (a) he/she was present when you dated and signed

the document, (b) you appeared to be of sound mind and free from duress at the time

you signed the document, and (c) he/she does not fall into any of the categories of

people who cannot be a witness.

Your witness cannot be:

•

related to you by blood, marriage, or adoption,

•

entitled to any part of your estate, by will or operation of law, at the time the

document is signed,

•

appointed as your agent, or

•

involved with the provision of your health care at the time the document is

signed.

2. Have your signature witnessed by a notary public who is neither your agent nor a

person involved with the provision of your health care at the time the document is

signed. The notary must also affirm that (a) he/she was present when you dated and

signed the document, (b) you appeared to be of sound mind and free from duress at

the time you signed the document. The notary cannot be appointed as your agent, or

involved with the provision of your health care at the time the document is signed.

Either option is available using this form.

If you are physically unable to sign your

Arizona Health

Care

Directive

your witness or

notary must add and sign a statement that you have indicated to him or her that the

health care directive expresses your wishes and that you wish to adopt the documents.

Instructions for Completing Your Arizona Health Care Directive (continued)

Can I add personal instructions to my

Liv i n

g W i l l ?

One of the strongest reasons for naming an agent is to have someone who can respond

flexibly as your medical situation changes and deal with situations that you did not

foresee. If you add instructions to this document it may help your agent carry out your

wishes, but be careful that you do not unintentionally restrict your agent’s power to act

in your best interest. In any event, be sure to talk with your agent about your future

medical care and describe what you consider to be an acceptable “quality of life.”

Whom should I appoint as my agent?

Your agent is the person you appoint to make decisions about your medical care if you

become unable to make those decisions yourself. Your agent may be a family member

or a close friend whom you trust to make serious decisions. The person you name as

your agent should clearly understand your wishes and be willing to accept the

responsibility of making medical decisions for you.

You can appoint a second person as your alternate agent. The alternate will step in if

the first person you name as an agent is unable, unwilling, or unavailable to act for you.

What if I change my mind?

If you wish to revoke your Arizona Health Care Directive, you may do so by:

•

a written revocation,

•

orally notifying your agent or health care provider of your revocation,

•

executing a new Health Care Power of Attorney, or

•

any other act that demonstrates your intent to revoke your document.

INSTRUCTIONS

PRINT YOUR NAME

PRINT THE

ARIZONA HEALTH CARE DIRECTIVE PAGE 1 OF 11

1. HEALTH CARE POWER OF ATTORNEY

I, , as principal,

(name)

designate

NAME,

HOME

ADDRESS, HOME

AND WORK

TELEPHONE

NUMBERS OF YOUR

AGENT

(name of agent)

(address)

_(home telephone number)

_(work telephone number)

as my agent for all matters relating to my health care, including, without

limitation, full power to give or refuse consent to all medical, surgical,

hospital and related health care. This power of attorney is effective on my

inability to make or communicate health care decisions. All of my agent’s

actions under this power during any period when I am unable to make or

communicate health care decisions or when there is uncertainty whether I

am dead or alive have the same effect on my heirs, devisees and personal

representatives as if I were alive, competent and acting for myself.

PRINT THE NAME,

HOME ADDRESS,

HOME AND WORK

TELEPHONE

NUMBERS OF YOUR

ALTERNATE

AGENT

If my agent is unwilling or unable to serve or continue to serve, I hereby

appoint

(alternate agent)

(address)

_(home telephone number)

_(work telephone number)

Hospice and

Palliative Care

Organization

as my agent.

INSTRUCTIONS

INITIAL THE

STATEMENT

THAT APPLIES

IN EACH

PARAGRAPH

Hospice and

Palliative Care

Organization

2019 Revised.

ARIZONA HEALTH CARE DIRECTIVE PAGE 2 OF 11

I have I have not completed the living will (Part 2 of the

Health Care Directive form) for purposes of providing specific direction to

my agent in situations that may occur during any period when I am

unable to make or communicate health care decisions or after my death.

My agent is directed to implement those choices I have initialed in the

living will.

I have I have not completed a prehospital medical care

directive pursuant to section 36-3251, Arizona Revised Statutes.

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ARIZONA HEALTH CARE DIRECTIVE PAGE 3 OF 11

2. LIVING WILL (OPTIONAL)

INITIAL ANY AND

ALL PARAGRAPHS

THAT REFLECT

Some general statements concerning your health care options are

outlined below. If you agree with one of the statements, you should

initial that statement. Read all of these statements carefully before you

initial your selection. You can also write your own statement concerning

life-sustaining treatment and other matters relating to your health care

under the section titled “Other or additional statements of desires.”

You may initial any combination of paragraphs 1, 2, 3 and 4 but

if you initial paragraph 5 the others should not be initialed.

YOUR WISHES

1. If I have a terminal condition I do not want my life to be

AND

CROSS THROUGH

STATEMENTS

THAT DO NOT

REFLECT YOUR

WISHES

YOU MAY ADD

ADDITIONAL

prolonged and I do not want life-sustaining treatment, beyond comfort

care (treatment given to protect and enhance my quality of life), that

would serve only to artificially delay the moment of my death.

2. If I am in a terminal condition or an irreversible coma or a

persistent vegetative state that my doctors reasonably feel 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

•

cardiopulmonary resuscitation, for example, the use of drugs,

electric shock and artificial breathing; or

•

artificially administered nutrition and hydration; or

•

to be taken to a hospital if at all avoidable.

3. Notwithstanding my other directions, 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.

STATEMENTS THAT

4. Notwithstanding my other directions I do want the use of all

REFLECT YOUR

WISHES ON

THE NEXT

PAGE

Hospice and

Palliative Care

Organization

2019 Revised.

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.

5. Regardless of my condition, I want my life to be prolonged

to the greatest extent possible.

ARIZONA HEALTH CARE DIRECTIVE PAGE 4 OF 11

ADD OTHER

INSTRUCTIONS, IF

ANY, REGARDING

YOUR ADVANCE

CARE PLANS

Other or additional statements of desires:

THESE

INSTRUCTIONS CAN

FURTHER ADDRESS

YOUR HEALTH CARE

PLANS, SUCH AS

YOUR WISHES

REGARDING

HOSPICE

TREATMENT, BUT

CAN ALSO ADDRESS

OTHER ADVANCE

PLANNING

ISSUES,

SUCH

YOUR

BURIAL

WISHES

ATTACH

ADDITIONAL PAGES

IF NEEDED

Hospice and

Palliative Care

Organization

2019 Revised.

ARIZONA HEALTH CARE DIRECTIVE PAGE 5 OF 11

INSTRUCTIONS

AUTOPSY

(OPTIONAL)

IF YOU CHOOSE TO

INITIAL A

STATEMENT,

INITIAL ONLY ONE

STATEMENT THAT

REFLECTS YOUR

WISHES

3. AUTOPSY (Optional)

(UNDER ARIZONA LAW AN AUTOPSY MAY BE REQUIRED IN CERTAIN

CIRCUMSTANCES)

If one of the statements below reflects your wishes, initial on the line next

to that statement. If you choose to initial a statement, initial only one

statement. You do not have to initial any of the statements.

1. I do not consent to an autopsy in any situation in which an

autopsy is not otherwise required by law.

2. I consent to an autopsy.

3. My agent may give consent to or refuse an autopsy.

Hospice and

Palliative Care

Organization

2019 Revised.

ARIZONA HEALTH CARE DIRECTIVE PAGE 6 OF 11

ORGAN

DONATION

INITIAL THE

4. ORGAN DONATION (OPTIONAL)

(Under Arizona

law, you may make a gift of all or part of your body to a

bank or

storage facility

or a

hospital, physician

medical

dental

school

for

transplantation, therapy, medical

or dental

evaluation

research

for the

advancement

medical

or dental

science.

You may also authorize

your

agent

to do so or a

member

of your

family

may

make

a gift unless

you give them notice that you do not want a gift made. In the space

below you may make a gift

yourself

or state that you do not want to make

a gift. If you do not

complete

this

section,

your

agent

will have the

authority

to make a gift of a part of your body

pursuant

to law. The

donation elections

you make below

survive

your death.)

If any of the statements below reflects your desire, initial on the line next

to that statement. You do not have to initial any of the statements. If you

do not initial any of the statements, your agent and your family will have

the authority to make a gift of all or part of your body under Arizona law.

STATEMENTS

I do not want to make an organ or tissue donation and I do not

THAT REFLECT

YOUR WISHES

want my agent or family to do so.

I have already signed a written agreement or donor card regarding

organ and tissue donation with the following individual or institution:

Pursuant to Arizona law, I hereby give, effective on my death:

Any needed organ or parts.

The following part or organs listed below:

Hospice and

Palliative Care

Organization

2019 Revised.

for (initial one):

Any legally authorized purpose.

Transplant or therapeutic purposes only.

ARIZONA HEALTH CARE DIRECTIVE PAGE 7 OF 11

PHYSICIAN

AFFIDAVIT

(OPTIONAL)

YOUR DOCTOR

SHOULD COMPLETE

THIS SECTION

5. PHYSICIAN AFFIDAVIT (OPTIONAL)

(Before initialing any choices in your Health Care Directive you may wish

to ask questions of your physician regarding a particular treatment

alternative. If you do speak with your physician it is a good idea to ask your

physician to complete this affidavit and keep a copy for his or her file.)

I, Dr. ,

have reviewed this guidance document and have discussed with

any questions regarding the probable medical consequences of the

treatment choices provided above. This discussion with the principal

occurred on .

(date)

I have agreed to comply with the provisions of this directive.

(signature of physician)

Hospice and

Palliative Care

Organization

2019 Revised.

ARIZONA HEALTH CARE DIRECTIVE PAGE 8 OF 11

FUNERAL AND

BURIAL

DISPOSITION

(OPTIONAL)

INITIAL THE

STATEMENTS THAT

REFLECT YOUR

WISHES

6. FUNERAL AND BURIAL DISPOSITION (OPTIONAL)

If any of the statements below reflects your desire, initial on the line next

to that statement. You do not have to initial any of the statements.

My agent has authority to carry out all matters relating to my funeral and

burial disposition wishes in accordance with this power of attorney, which

is effective upon my death. My wishes are as follows:

Upon my death, I direct my body to be buried (as opposed to

cremated).

Upon my death, I direct my body to be buried in .

Upon my death, I direct my body to be cremated.

Upon my death, I direct my body to be cremated, with my ashes to

be .

My agent may make all funeral and burial disposition decisions.

Hospice and

Palliative Care

Organization

2019 Revised.

ARIZONA HEALTH CARE DIRECTIVE PAGE 9 OF 11

EXECUTION

This Health Care Directive will not be valid unless it is EITHER:

IF YOU CHOOSE TO

SIGN WITH A

WITNESS, USE

ALTERNATIVE 1,

BELOW

IF YOU CHOOSE TO

HAVE YOUR

SIGNATURE

NOTARIZED, USE

ALTERNATIVE 2,

BELOW

Hospice and

Palliative Care

Organization

2019 Revised.

(A) Signed by at least one qualified adult witness who is present when

you sign and who affirms that you appear to be of sound mind and are

under no duress. The witness cannot be related to you by blood,

marriage, or adoption, entitled to any part of your estate at the time the

document is signed, appointed as your agent, or involved with the

provision of your health care at the time the document is signed. (Use

Alternative 1, below, if you decide to have your signature witnessed.)

(B) Witnessed by a notary public who is neither your agent nor a person

involved with the provision of your health care at the time the document

is signed. The notary must also affirm that (a) he/she was present when

you dated and signed the document, (b) you appeared to be of sound

mind and free from duress at the time you signed the document. (Use

Alternative 2, below, if you decide to have your signature notarized.)

OTE: I

f the

incipa

l is

physically una

e to

sig

ealt

h Care

Dir

ect

ive, the

ess or

otary

ust

dd a

sta

tem

ent

“

princi

pal has

dir

ectly indica ted to

hat

lth Care

Directiv

expr

esses his or

her

hes and

tha

t the

inci

pal

ten

ds to

ado

t this

Heal

Car

Dir

ect

ive at

his

time

.”

ARIZONA HEALTH CARE DIRECTIVE PAGE 10 OF 11

INSTRUCTIONS

SIGN AND DATE

THE DOCUMENT

OPTION 1: Sign before a Witness

This health care directive is made under Section 36-3221, Arizona Revised

Statutes, and continues in effect for all who may rely on it except those to

whom I have given notice of its revocation.

(signature of principal)

(date) (time)

WITNESSING

PROCEDURE

I affirm that this was signed or acknowledged and dated in my presence,

and that the person signing this document (the principal) appears to be of

sound mind and under no duress. I am not designated to make medical

decisions on the principal’s behalf. I am not directly involved with the

provision of health care to the principal. I am not entitled to any portion of

the principal’s estate upon his or her decease, whether under any will or

by operation of law. I am not related to the principal by blood, marriage,

or adoption.

WITNESS MUST

SIGN AND PRINT

HIS OR HER

ADDRESS

Witness:

Date:

Address:

WITNESS

MUST SIGN

THIS

STATEMENT

IF PRINCIPAL

PHYSICALLY

UNABLE TO

SIGN

National

Hospice and

Palliative Care

Organization

2019 Revised.

Note: If the principal is physically unable to sign the Health Care

Directive, the Witness must sign the following statement:

The principal has directly indicated to me that this

Health Care Directive expresses his or her wishes and

that the principal intends to adopt this Health Care

Directive at this time.

Witness:

Date:

ARIZONA HEALTH CARE DIRECTIVE PAGE 11 OF 11

INSTRUCTIONS

SIGN AND DATE

THE DOCUMENT

OPTION 2: Sign Before a Notary

This health care directive is made under Section 36-3221, Arizona Revised

Statutes, and continues in effect for all who may rely on it except those to

whom I have given notice of its revocation.

(signature of principal)

(date) (time)

State of Arizona

County of

The foregoing instrument was signed or acknowledged before me this

day of _, _, by

NOTARY WILL FILL

OUT THIS PART OF

THE FORM

(principal).

The person signing this document (the principal) appears to be of sound

mind and is under no duress. I am not designated to make medical

decisions on the principal’s behalf. I am not directly involved with the

provision of health care to the principal.

NOTARY PUBLIC

Print Name:

My Commission Expires:

NOTARY MUST SIGN

THIS STATEMENT IF

PRINCIPAL IS

PHYSICALLY

UNABLE TO SIGN

Hospice and

Palliative Care

Organization

2019 Revised

Note: If the principal is physically unable to sign the Health Care

Directive, the Notary must sign the following statement:

The principal has directly indicated to me that this Health

Care Directive expresses his or her wishes and that the

principal intends to adopt this Health Care Directive at

this time.

Notary: Date:

You Have Filled Out Your Health Care Directive, Now What?

1. Your

Arizona Health

Care

Directive

is an important legal document. Keep the

original signed document in a secure but accessible place. Do not put the

original document in a safe deposit box or any other security box that would

keep others from having access to it.

2. Give photocopies of the signed original to your agent and alternate agent,

doctor(s), family, close friends, clergy and anyone else who might become

involved in your health care. If you enter a nursing home or hospital, have

photocopies of your document placed in your medical records.

3. Be sure to talk to your agent(s), doctor(s), clergy, family and friends about your

wishes concerning medical treatment. Discuss your wishes with them often,

particularly if your medical condition changes.

4. Arizona maintains an Advance Directive Registry. By filing your advance directive

with the registry, your health care provider and loved ones may be able to find a

copy of your directive in the event you are unable to provide one. You can read

more about the registry, including instructions on how to file your advance

directive, at https://www.azsos.gov/adv_dir/.

5. You may also want to save a copy of your form in an online personal health

records application, program, or service that allows you to share your medical

documents with your physicians, family, and others who you want to take an

active role in your advance care planning.

6. If you want to make changes to your documents after they have been signed

and witnessed, you must complete a new document.

7. Remember, you can always revoke your Arizona document.

8. Be aware that your Arizona document will not be effective in the event of a

medical emergency. Ambulance and hospital emergency department personnel

are required to provide cardiopulmonary resuscitation (CPR) unless they are

given a separate directive that states otherwise. These directives called

“prehospital medical care directives” or “do not resuscitate orders” are designed

for people whose poor health gives them little chance of benefiting from CPR.

These directives instruct ambulance personnel, hospital emergency personnel

and direct care staff persons not to attempt CPR if your heart or breathing

should stop.

The directives must be in the form required by the Arizona Department of Health

Services, and must be signed by you, your physician, and a witness. A form can

be found online at http://www.azag.gov/life_care/. We suggest you speak to

your physician for more information. Caringinfo does not distribute these

forms.

OR donate online today: www.NationalHospiceFoundation.org/donate

Congratulations!

You’ve downloaded your free, state specific advance directive.

You are taking important steps to make sure your wishes are known. Please consider helping us

keep this resource free.

Your generous support to the National Hospice Foundation allows us to continue to provide FREE

resources, tools, and information to educate and empower individuals to access advance care

planning, caregiving, hospice and grief services.

Please show your support for our mission and consider making a tax-deductible gift

to the National Hospice Foundation today.

Since 1992, the National Hospice Foundation has been dedicated to creating FREE resources for

individuals and families facing a life-limiting illness, raising awareness for the need for hospice

and palliative care, and providing ongoing professional education and skills development to

hospice and palliative care professionals across the nation. To learn more, please visit

www.NationalHospiceFoundation.org

You may wonder if a gift of $35, $50 or $100 to the National Hospice Foundation would make a

difference, but it is only because of the generosity of others like you that these FREE resources

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Please consider supporting our mission by returning a generous tax-deductible donation.

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Return to:

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PO Box 824401

Philadelphia, PA 19182-4401

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