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LIVING WILL FOR
______________________
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:
It is my desire that, to the extent reasonable and practical, my agent who is acting pursuant to this Living Will consult with all of my immediate family members before exercising the authority granted in this Living Will. The attending physicians or other health care providers are not required to determine if any or all of the above named persons or other immediate family members have been consulted. Any physician or other health care provider may rely on the avowal of authority of any secondarily-named agent if that agent provides a written statement as to why the previously-named agents cannot make health care decisions for me.
Resolution of Disputes. 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. I do not want the following individuals to participate in or in any way influence a decision made by my agents:
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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 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 any of these factors to be indicative of a significantly diminished quality of life:
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 regardless of any medical treatment that I may receive or that is otherwise available. It is my intent and strong desire to avoid a “Terry Schiavo” situation. To accomplish this, 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 the authority granted by me in this Living Will., to include litigation for injunctive relief and/or damages.
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.
______________________________ ______________________ DATE
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.
Witness: _____________________________ Date: _______________________
Print name: ___________________________
Address: _____________________________
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