Arizona Living Will Template
This Living Will is designed in accordance with the Arizona Life Care Planning (A.R.S. §§ 36-3201 to 36-3291) to record your wishes regarding medical treatment if you become unable to communicate your decisions due to illness or incapacity.
Personal Information
Full Name: ___________________________________________________
Address: _____________________________________________________
City: _________________________ State: AZ Zip Code: ___________
Date of Birth: _______________ Phone Number: ________________________
Healthcare Directive
I, __________________________________ [insert your name], being of sound mind, hereby direct that my health care providers and others involved in my care carry out the following instructions regarding my healthcare and medical treatment.
Life-Sustaining Treatment
If I am in any of the following conditions, I direct that life-sustaining measures that serve only to prolong the dying process or maintain me in a permanent unconscious condition be withheld or withdrawn:
- In a terminal condition where recovery is impossible
- In a persistent vegetative state or permanent unconsciousness
- In a condition of advanced dementia or any other condition resulting in the substantial loss of cognitive ability and there is no reasonable expectation of recovery
Nutrition and Hydration
Artificial nutrition and hydration (feeding tube) should be:
- Provided in all circumstances.
- Withheld or withdrawn if the burdens outweigh the expected benefits.
- Withheld or withdrawn if I am permanently unconscious or in a terminal condition as described above.
Pain Relief
I wish to receive treatment to relieve pain and suffering, even if such treatments may indirectly shorten my life, provided that they do not intentionally hasten death.
Primary Healthcare Power of Attorney
I designate the following person as my healthcare agent to make healthcare decisions for me, should I become incapable of making my own decisions:
Name: _______________________________________________
Relationship: ________________________________________
Address: ______________________________________________
Phone Number: _________________________________________
Alternate Healthcare Power of Attorney
If my primary agent is unable, unwilling, or unavailable to act in my behalf, I designate the following person as my alternate healthcare agent:
Name: _______________________________________________
Relationship: ________________________________________
Address: ______________________________________________
Phone Number: _________________________________________
Signatures
My signature below indicates that I understand the purpose and effect of this document and that I am aware of my right to revoke this directive at any time.
_____________________________________
Signature of Principal
Date: _______________
This document was signed in the presence of two witnesses, not related to me by blood or marriage, not entitled to any part of my estate, and not directly financially responsible for my medical care.
Witness 1 Signature: ________________________________
Print Name: ________________________________
Date: _______________
Witness 2 Signature: ________________________________
Print Name: ________________________________
Date: _______________