Life Care Planning: Office of Arizona Attorney General,
Living Will – Updated 11/2019 Mark Brnovich
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OFFICE OF THE ARIZONA ATTORNEY GENERAL
My Information (I am the “Principal”):
Name: ______________________________ Date of Birth: ________________________
Address: ____________________________ Phone: _____________________________
____________________________ Email: ______________________________
Some general statements about your health care choices are listed below. If you agree with one of
the statements, you should initial that statement. Read all of these statements carefully BEFORE you
initial your preferred statement. You can also write your own statement concerning life-sustaining
treatment and other matters relating to your health care. You may initial any combination of
paragraphs 1, 2, 3 and 4, BUT if you initial paragraph 5 the others should not be initialed.
_____ 1. 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.
**Comfort care is treatment given in an attempt to protect and enhance the
quality of life without artificially prolonging life.
_____ 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
_____ a. Cardiopulmonary resuscitation (CPR). For example: the use of drugs, electric
shock and artificial breathing.
_____ b. Artificially administered food and fluids.
_____ c. To be taken to a hospital if at all avoidable.
_____ 3. 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pregnant, I do not want life-sustaining treatment withheld or withdrawn if it is possible that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 live birth with the continued application of life-
_____ 4. Regardless of any other directions I have given in this Living Will, I do want the use of all
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. I want my life to be prolonged to the greatest extent possible (If you initial here, you should
not initial any of the others).
PLEASE NOTE: You can attach additional instructions on your medical care wishes 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 instructions about End of Life Care I want.
_____ B. I HAVE attached additional special provisions or limitations about End of Life Care I want.