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Fill and Sign the Statutory Living Will Arizona Form

Fill and Sign the Statutory Living Will Arizona Form

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LIVING WILL (Arizona Revised Statutes 36-3262) (Some general statements concerning your health care options are outlined below. If you agree with one of the statements, you should initial that statement. Read all of these statements carefully before you initial your selection. 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. _____ 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, 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Notwithstanding my other directions, if I am known to be pregnant, I do not want life- sustaining treatment withheld or withdrawn if it is possible that the embryo/fetus will develop to the point of live birth with the continued application of life-sustaining treatment.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 my 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. _____ 5. I want my life to be prolonged to the greatest extent possible. Other or Additional Statements of Desires I have I have not attached additional special provisions or limitations to this document to be honored in the absence of my being able to give health care directions. This Living Will/health care directive is made under section 36-3261 et seq. , Arizona Revised Statutes, and continues in effect for all who may rely on it except those to whom I have given notice of its revocation. __________________________________________ Signature of Principal AFFIRMATION OF WITNESSES I affirm that the person signing this living will power of attorney: 1. Is personally known to me. 2. Signed or acknowledged by his or her signature on this declaration in my presence. 3. Appears to be of sound mind and not under duress, fraud or undue influence. 4. Is not related to me by blood, marriage or adoption. 5. Is not a person for whom I directly provide care as a professional. 6. Has not appointed me as an agent to make medical decisions on his or her behalf. Witness Signature: Witness Name: Address: Witness Signature: Witness Name: Address:

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