Arizona Living Will
This Arizona Living Will is a legal document that outlines your healthcare preferences in the event that you are unable to communicate your wishes due to incapacity. This document is made in accordance with the Arizona Life Care Planning statutes, ensuring that your healthcare decisions are respected and followed.
Personal Information
Full Name: ___________________
Date of Birth: ___________________
Address: ___________________
City: ___________________ State: AZ Zip Code: ___________________
Phone Number: ___________________
Healthcare Directives
In the event that I am incapacitated and unable to express my healthcare wishes, I direct my healthcare providers to follow the instructions outlined in this document.
Life-Sustaining Treatment
If I am in any of the following conditions, I direct my healthcare providers as follows:
- In a terminal condition where death is imminent despite the introduction or continuation of medical treatments: _________________________________________
- In a persistent vegetative state that a healthcare professional believes to be irreversible: _________________________________________
- In a condition where the expected risks and burdens of treatment outweigh the expected benefits: _________________________________________
Artificial Nutrition and Hydration
Regarding the provision or withholding of artificially provided food and water (tube feeding):
_________________________________________
Healthcare Agent
In the event I am unable to make my own healthcare decisions, I designate the following individual as my Healthcare Agent to make any and all health care decisions for me, consistent with my desires and the wishes expressed in this document.
Name: ___________________
Relationship: ___________________
Phone Number: ___________________
Alternate Phone Number: ___________________
Signatures
This Living Will shall remain in effect until I revoke it or it is replaced by a new one. I understand that I may revoke or amend this Living Will at any time by communicating my wishes in writing.
Date: ___________________
_________________________________________
Signature
Witness:
I declare that the person who signed or acknowledged this document is personally known to me, that he/she signed or acknowledged this Arizona Living Will in my presence, and that he/she appears to be of sound mind and under no duress, fraud, or undue influence.
Name: ___________________
Date: ___________________
_________________________________________
Signature