LIVING WILL
(No Heroic Measures)
FOR
N-1
Pursuant to Arizona Revised Statute Sec. 36-3261 and effective immediately, I hereby create a Living Will in which I provide that my agent or agents designated below shall have authority to make decisions and implement my desires regarding my current or future medical care in the event that I become terminally or seriously ill as defined below. By completing this document, I revoke all prior living wills
Appointment of agent. I appoint the following persons, in the order of priority set forth below, to act as my agent for purposes of this Living Will:
1.
2.
3.
Resolution of Disputes. It is my intent and strong desire to avoid a "Terry Schiavo" situation. In the event that there is disagreement or dispute among my family members as to my intentions in matters governed by this Living Will, my duly authorized agent shall make the final and binding determination of what my intentions are or would be if I was capable of making my intentions known at that time.
In the event of dispute regarding any care provided to or withdrawn from me, no one other than my ( ) children shall have any input or influence in rendering a decision.
Purpose and Intentions. Although I value life, I also believe that, due to injury, disease or having reached an advanced age, life has such diminished value that medical treatment should be stopped and that I should be allowed to die. I am completing this document so that my agent and family members can make the best decision with the least amount of guilt. I do not want my life extended by medical interventions, including artificially administered nutrition and hydration, when such treatments will not improve or reverse my medical condition or otherwise give me a meaningful quality of life.
In regards to my quality of life, I consider the existence of a majority of the factors that I have initialed to be indicative of a significantly diminished quality of life:
______ Inability to make or communicate responsible decisions about my personal matters
______ Inability to walk without the assistance of others or a wheel chair
______ Experiencing pain most of the time
______ Experiencing discomfort (such as nausea, diarrhea, shortness of breath or weakness) most of the time
______ Inability to control my bladder and bowels
______ Having a feeding tube inserted into my stomach and/or being unable to be fed by a spoon
______ Use of a ventilator that is required to keep me alive
______ Inability to recognize family or close friends
______ Incurring costs for the provision of medical care that will create a financial hardship for me, my family or other loved ones
If I become terminally ill, I direct my agent to cease or withhold all medical interventions, except for the treatment of pain relief, if my doctors have diagnosed me as terminally ill and I am in an irreversible coma or persistent vegetative state.
For purposes of this paragraph, "terminally ill" means a condition that my doctors believe, to a reasonable degree of medical certainty, will result in my death within six months if my condition runs its normal course. For purposes of this document, a terminally ill condition includes a) a diagnosis of Alzheimer's disease or other form of dementia or b) any stroke, trauma to my brain or other severe brain injury that I may have suffered, even though I realize that these conditions are not otherwise be considered to be terminal by the medical community.
Pain-free Death. I do not want my death to be painful. My doctors are authorized to provide to me medication of any type or form that can be administered by any medically acceptable means. I authorize the use of such medication even if the medication will have adverse cardiac or respiratory consequences, create an addiction, cause drowsiness, hallucinations or confusion or otherwise hasten my death.
Organ, Tissue and Parts Donation. Upon my death,
______ I do not wish to donate any organs, tissue or body parts
______ I give any or all of my organs and tissues but not my body parts
______ I give any or all of my organs, tissues and body parts
Lawsuits. My agent is authorized to initiate, defend or otherwise participate in any legal proceedings that may be necessary to implement my desires and the authority granted by me in this Living Will, to include litigation for injunctive relief and/or damages against any health care provider, family member or other individual or entity who fail to honor my desires as stated in this document.
HIPAA Release Authority. I intend for my agent to be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (aka HIPAA), 42 USC 1320d and 45 CFR 160-164.
Copies. If the original copy of this Living Will has not or cannot be provided to my health care provider or other party, then any such provider or party may rely on a photocopy, digital image or other reproduction provided by Murphy law Firm, Inc that certifies that the copy is a true and accurate copy of the original.
______________________________ d-t
N-1
I affirm that this was signed or acknowledged in my presence, and that the person signing this document (the principal) appears to be of sound mind and under no duress. I am at least 18 years of age. I am not designated to make medical decisions on the principal's behalf. I am not directly involved with the provision of health care to the principal. I am not entitled to any portion of the principal's estate upon his or her death, whether under any will or by operation of law. I am not related to the principal by blood, marriage or adoption.
d-t
Paralegal (Name), Witness
STATE OF ARIZONA )
COUNTY OF ( ) ss.
Subscribed, sworn to, and acknowledged before me by N-1 and subscribed and sworn to before me by (Paralegal), a witness, this d-t.
Attorney Name
Attorney at Law/Notary Public
STATE OF ARIZONA )
COUNTY OF ( ) ss.
Subscribed, sworn to, and acknowledged before me by N-1 and subscribed and sworn to before me by (Attorney Name), a witness, this d-t.
Name, Notary Public
LIVING WILL
PRINCIPAL:
N-1
AGENT:
CO-AGENT:
CO-AGENT:
