LIVING WILL FOR

JOHN DOE

 

Pursuant to Arizona Revised Statute 36‑3261, I hereby create a Living Will in which I provide my agent, as designated below, or to my health care provider with guidance about my health care in the event that I am BOTH unconscious or mentally incapacitated AND suffering from an incurable or terminal condition or irreversible coma. For purposes of this instrument, Aterminal condition@ shall refer to a condition or disease that is reasonably expected to result in my death within twelve months regardless of any treatment that I may receive. AIrreversible coma@ shall refer to a permanent loss of consciousness from which there is no reasonable possibility that I will return to a cognitive and sapient life and shall include, but not be limited to, a persistent or permanent vegetative state.

 

Notwithstanding any other guidance or directives that I may provide, I DO want the use of all medical care necessary to treat my condition until my doctors reasonably conclude that my condition is incurable or terminal AND that I will remain in an irreversible coma.

 

I desire that this Living Will be applicable in all states and countries. In the event that this Living Will is not legally binding in the jurisdiction where I am being cared for, it is my hope that my agent designated below will feel morally bound to follow my wishes as expressed in this Living Will.

 

APPOINTMENT OF AGENT.

I appoint the following persons, in the order of priority set forth, to act as my agent for purposes of this Living Will to make decisions and implement my desires regarding my current or future health care treatment:

 

1.   N-2 - (state relationship)

2.   N-3 - (state relationship)

3.   N-4 - (state relationship)

 

It is my desire that, to extent reasonable and practical, my agent who is acting pursuant to this Living Will consult with all of the above named persons before exercising the authority granted in this Living Will. Neither the attending physician nor the hospital is required to determine if any or all of the above named persons have been consulted or the reason why certain individuals may not have been contacted or consulted. Any physician or other health care provider may rely on the avowal of authority of any secondarily‑named agent acting on my behalf if that agent provides a written statement to the person with whom he is dealing as to why any of the previously‑named agents cannot make health care treatment decisions for me.

 

POWERS OF AGENT.

The powers set forth below are effective only if I am unable to provide informed consent to health care treatment that is proposed or available for my condition because I am unconscious or mentally incapacitated AND my condition is incurable, terminal or I am in an irreversible coma, my agent is authorized to:

 

A.   Direct that health care treatment which will serve only to postpone the moment of my death or prolong an irreversible coma, whether or not such treatment is directed toward my terminal condition, be withheld or, if previously begun, to direct that such treatment be withdrawn, whether or not such treatment is related to (i) the incurable and terminal condition or irreversible coma described above or (ii) other illnesses, diseases or conditions.

 

B.   To request , require or consent to the writing of a Ano Code@ or ADo Not Resuscitate@ order.

 

C.   To order whatever is appropriate to keep me as comfortable and free of pain as is reasonably possible, including the administration of pain relieving drugs of any kind or other surgical or medical procedures calculated to relieve my pain, including any unconventional pain relief therapies which my attending physician believes may be helpful, even though such drugs or procedures may lead to permanent physical damage, addiction or which may hasten the moment, but not intentionally cause, my death.

 

D.   To sign on my behalf any documents necessary to carry out the authorizations described in this instrument, including waivers or releases of liability of any physician or health care provider.

 

E.   To refuse to consent to or terminate intravenous, gastric or naseogastric feeding if I am no longer able to eat or drink in a normal manner.

 

F.   To refuse to consent to or terminate any parenteral or oral antibiotics which could be considered as life saving if I contract any infections, including pneumonia. However, if such treatment is needed to prevent the spread of contagious infection or will make nursing care easier, then such treatment may be given to me. Urinary tract infections can be treated only by the oral route. Topical treatment may be provided to improve nursing care.

 

G.   To refuse to allow me to be taken to a hospital for treatment if I am at home and can be reasonably treated there.

 

H.   To initiate any legal  proceeding that may be necessary to implement the authority granted by me in this Living Will, to include litigation for injunctive relief and/or damages.

 

I.          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 and shall constitute both consent and authorization for the use and disclosure of my records as those terms are defined under the HIPAA Privacy Rule.  I authorize:

 

(1)        any physician, healthcare professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or other covered health care provider and any insurance company and Medical Information Bureau Inc. Medical Information Bureau Inc that has provided treatment or services to me or that has paid for or is seeking payment  from me for such services,

 

(2)         to give, disclose and release to my agent, without restriction,

 

(3)                 all of my individually identifiable health information and medical records regarding any past, present or future medical or mental health condition, to include  all information relating to the diagnosis and treatment of HIV/AIDS, sexually transmitted diseases, mental illness and drug or alcohol abuse.

 

I have carefully read and reviewed this document in its entirety and hereby express my agreement with its contents by signing below.

 

DATED THIS d-t.                                                                      By:                                                                       


     JOHN DOE, Principal

 

The witnesses who sign below a) are not named as an agent for the person who signed this Living Will, b) are not directly involved with the provision of health care to the person who signed this Living Will at the time it was signed, and c) are not related to the person signing this Living Will by blood, marriage, or adoption or otherwise entitled to receive any part of the estate of the person who signed this Living Will.

 

 

 

 

                                                              

(Name of Witness), Witness

 

                                                                    

(Name of Witness), Witness

 

STATE OF ARIZONA            )

) ss.

COUNTY OF MARICOPA    )

 

Subscribed, sworn to, and acknowledged before me by JOHN DOE and subscribed and sworn to before me by                                                 and                                          , Witnesses, this d-t.

 

 

  (Name of Notary), Notary Public

 

 

 

 

 

 

 

 

 

 

 

LIVING WILL

 

PRINCIPAL:

JOHN DOE

N1-ad

N1-tl

 

AGENT:

N-2

N2-ad

N2-tl

 

 

FIRST ALTERNATE AGENT:

N-3

N3-ad

N3-tl

 

 

SECOND ALTERNATE AGENT:

N-4

N4-ad

N4-tl