1
ARIZONA
Advance Directive
Planning for Important Health Care Decisions
Caring
I
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.
Copyright © 2005 National Hospice and Palliative Care Organization. All rights reserved. Revised 2019.
Reproduction and distribution by an organization or organized group without the written permission of
the National Hospice and Palliative Care Organization is expressly forbidden.
2
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.
3
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
of
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.
4
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.
OR
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.
5
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.
6
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)
© 2005 National
Hospice and
Palliative Care
Organization
as my agent.
7
INSTRUCTIONS
INITIAL THE
STATEMENT
THAT APPLIES
IN EACH
PARAGRAPH
© 2005 National
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.
N
ot
e: A
p
reh
ospi
tal
m
ed
ical care
dir
ecti
ve
m
us
t be in
th
e form
requir
ed by
th
e
A
riz
ona
D
epar
tm
en
t of
H
eal
th
Services, an
d
m
u
st be
s
ign
ed by
yo
u,
yo
u
r
physician,
and a
w
i
tn
ess
. A form can be
fou
nd
o
nline at
ht
tp:/ /
w
w
w
.az
ag.gov/ l
i
fe_
care/
.
W
e
s
ug
ges
t
y
ou
s
peak
t
o
yo
ur
physici
an for
m
or
e
inform
a
tio
n.
Carin
g
I
nfo
do
es
n
ot
dis
tri
bu
t
e
thes
e
fo
rm
s.
8
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
© 2005 National
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.
9
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
AS
YOUR
BURIAL
WISHES
ATTACH
ADDITIONAL PAGES
IF NEEDED
© 2005 National
Hospice and
Palliative Care
Organization
2019 Revised.
10
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.
© 2005 National
Hospice and
Palliative Care
Organization
2019 Revised.
11
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
or
medical
or
dental
school
for
transplantation, therapy, medical
or dental
evaluation
or
research
or
for the
advancement
of
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:
© 2005 National
Hospice and
Palliative Care
Organization
2019 Revised.
for (initial one):
Any legally authorized purpose.
Transplant or therapeutic purposes only.
12
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)
© 2005 National
Hospice and
Palliative Care
Organization
2019 Revised.
13
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.
© 2005 National
Hospice and
Palliative Care
Organization
2019 Revised.
14
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
© 2005 National
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.)
OR
(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.)
N
OTE: I
f the
pr
incipa
l is
physically una
bl
e to
sig
n
t
he
H
ealt
h Care
Dir
ect
ive, the
w
i
tn
ess or
n
otary
m
ust
a
dd a
sta
tem
ent
t
ha
t
Th
e
princi
pal has
dir
ectly indica ted to
m
e
t
hat
t
hi
s
He
lth Care
Directiv
e
expr
esses his or
her
w
is
hes and
tha
t the
pr
inci
pal
in
ten
ds to
ado
p
t this
Heal
th
Car
e
Dir
ect
ive at
t
his
time
.”
15
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
IS
PHYSICALLY
UNABLE TO
SIGN
© 2005
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:
16
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
© 2005 National
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:
17
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
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