LIVING WILLRead the
WARNING! first.
A.R.S. §36-3261 I, the undersigned
(hereinafter referred to as "MAKER"), believe that human life is both
precious and sacred from beginning to end; I believe that a right to die
with dignity, freedom and self-determination exists; I believe that I have
a fundamental right to control decisions relating to my own medical care,
including the decision to have artificial, extraordinary or heroic medical
procedures calculated to prolong life discontinued, even after I am no
longer able to participate actively in decisions concerning myself. Therefore, I hereby make the following declaration: I am of sound mind and I willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below. I further declare that if at any time I should have an incurable injury, disease or illness certified to be a terminal condition, or if I should be in a permanent vegetative state or in an irreversible coma as certified by two physicians who have personally examined me, one of whom is my attending physician, and the physicians have determined that my death will occur unless life-sustaining procedures are used and if the application of life-sustaining procedures would serve only to artificially prolong the dying process, I direct that the instructions I have indicated below (by a check, an "x" or by my initials) be followed by those individuals providing health care services to me: _____ 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. _____ 2. If I am in a terminal condition or in an irreversible coma or in 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, 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. Notwithstanding my other directions, if I am known to be pregnant, I do not want life-sustaining treatment withheld or withdrawn if it is possible that the embryo/fetus will develop to the point of live birth with the continued application of life-sustaining treatment. _____ 4. Notwithstanding any other directions 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. In the absence of my ability to give directions regarding the use of life-sustaining procedures, it is my intention that this declaration be honored by my family, by my personal representative/executor, and by my attending physician as the final expression of my legal right to refuse medical or surgical treatment and I personally accept the consequences from such refusal rather than their considering the consequences to be theirs. I understand the full extent
of this declaration, and I have the emotional and mental capacity to make
this declaration. I know what I am doing. Dated: _______________ MAKER's signature: _________________________ Witness Statement Each witness who signs this Living Will declares under penalty of perjury that such witness was present when the MAKER dated and signed this Living Will. Witness Signature: _________________________ Witness Address: _________________________ Witness Signature: _________________________ Witness Address:
_________________________ NOTE: This Living Will must be notarized or witnessed. Notarization STATE OF ARIZONA )
) ss.
County of ______ )
On this the ____ day of ___________, 200___, MAKER and _____________________ and ____________________ personally appeared before me, the undersigned Notary Public, known to me (or satisfactorily proven) to be the persons whose names are subscribed to the foregoing Living Will and acknowledged that they executed the same for the purpose therein expressed. IN WITNESS WHEREOF, I have hereunto set my hand and official seal. Notary Public signature: ______________________________ My Commission Expires: _______________ |
