Fillable LIVING WILL (End of Life Care) Instructions GENERAL (Arizona Attorney General)

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LIVING WILL (End of Life Care) Instructions GENERAL (Arizona Attorney General)

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Life Care Planning: Office of Arizona Attorney General,
Living Will – Updated 11/2019 Mark Brnovich
1 of 3
LIVING WILL (End of Life Care)
Instructions
GENERAL INSTRUCTIONS: Use this form to make decisions now about your medical care if you are
ever in a terminal condition, a persistent vegetative state or an irreversible coma. You should talk to
your doctor about what these terms mean.
The Living Will is your written directions to your health care power of attorney, also referred to as your
“agent”, your family, your physician, and any other person who might make medical care decisions for
you if you are unable to communicate yourself.
It is a good idea to talk to your doctor and loved ones if you have questions about the type of care you
do or do not want.
IMPORTANT: If you have a Living Will and a Health Care Power of Attorney, you must attach
the Living Will to the Health Care Power of Attorney.
If you fill out this form, make sure you DO NOT SIGN UNTIL your witness or a notary public is
present to watch you sign it.
PLEASE NOTE: At least one adult witness, not to include the proxy if there is one, OR a notary public
must witness you signing this document.
DO NOT have the documents signed by both a witness and a notary, just pick one. If you do not
know a notary or cannot pay for one a witness is legally accepted.
Witnesses 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 agent
(e) involved in providing your health care at the time this form is signed
Life Care Planning: Office of Arizona Attorney General,
Living Will – Updated 11/2019 Mark Brnovich
2 of 3
OFFICE OF THE ARIZONA ATTORNEY GENERAL
MARK BRNOVICH
Living Will
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
following:
_____ 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-
sustaining treatment.
_____ 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.
Life Care Planning: Office of Arizona Attorney General,
Living Will – Updated 11/2019 Mark Brnovich
3 of 3
MY SIGNATURE VERIFICATION FOR THE LIVING WILL
My Signature (Principal): _____________________________________ Date: _________________
If you are unable to physically sign this document your witness/notary may sign and initial for
you. If applicable, have your witness/notary sign below.
Witness/Notary Verification: The principal of this document directly indicated to me that this Living Will
expresses their wishes and that they intend to adopt it at this time.
Witness/Notary Signature: __________________________________________________________
Name Printed: ______________________________________________ Date: _________________
SIGNATURE OF WITNESS
I was present when this form was signed (or marked). The principal appeared to be of sound mind
and was not forced to sign this form.
Witness Signature: __________________________________________ Date: ________________
Name Printed: ____________________________________________________________________
Address: _________________________________________________________________________
OR
SIGNATURE OF NOTARY
Notary Public (NOTE: If a witness signs your form, you SHOULD NOT have a notary sign):
NOTORIAL JURAT: Pertains to all three pages of this Living Will
Dated ____________, 20____________.
STATE OF ARIZONA) ss
COUNTY OF ______________)
________________________________________________
Principals Name
Subscribed and sworn (or affirmed) before me this ___________ day of ________, 20 ______
Notary Public Signature: ____________________________________
My Commission Expires: _____________________
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LIVING WILL (End of Life Care) Instructions GENERAL (Arizona Attorney General)

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Completed 20 July 2020

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