ARIZONA ADVANCE HEALTH CARE DIRECTIVE
(Combined Living Will & Health Care Power of Attorney)
[// GUIDANCE: This template is drafted to comply with A.R.S. § 36-3201 et seq. and related provisions of Title 36, Chapter 32. All bracketed text must be completed or removed prior to execution. Replace or delete guidance comments.]
TABLE OF CONTENTS
- DOCUMENT HEADER
- DEFINITIONS
- APPOINTMENT OF HEALTH CARE AGENT
- LIVING WILL DIRECTIVES
- ORGAN, TISSUE, AND BODY DONATION (OPTIONAL)
- HIPAA AUTHORIZATION
- REVOCATION & AMENDMENT PROCEDURES
- RELIANCE, INDEMNIFICATION & LIABILITY CAPS
- GOVERNING LAW & DISPUTE RESOLUTION
- GENERAL PROVISIONS
- EXECUTION, WITNESS, AND NOTARIZATION
1. DOCUMENT HEADER
THIS ARIZONA ADVANCE HEALTH CARE DIRECTIVE (this “Directive”) is made as of [EFFECTIVE DATE] (the “Effective Date”) by [PRINCIPAL FULL LEGAL NAME], born [PRINCIPAL DOB], residing at [PRINCIPAL ADDRESS] (the “Principal”).
Recitals
A. The Principal desires to (i) designate a health care decision-maker (“Agent”) pursuant to A.R.S. § 36-3221 and (ii) express clear instructions concerning medical treatment in the event the Principal becomes unable to participate in health-care decisions.
B. This Directive is intended to be relied upon by health-care providers acting in good faith and in accordance with A.R.S. Title 36, Chapter 32.
2. DEFINITIONS
For purposes of this Directive, capitalized terms have the meanings set forth below; undefined capitalized terms shall have the meanings assigned in A.R.S. § 36-3201 et seq.
“Agent” – The individual appointed in Section 3 with authority to make health-care decisions for the Principal.
“Artificial Nutrition and Hydration” – Provision of nutrients or fluids through a medical device, including but not limited to intravenous, subcutaneous, or enteral feeding tubes.
“Comfort Care Measures” – Actions to maintain comfort (e.g., pain management, oxygen, oral hydration) that do not artificially prolong life.
“Health-Care Decision” – Any consent, refusal, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat the Principal’s physical or mental condition.
“Life-Sustaining Treatment” – Any medical intervention that, when administered to a patient with a terminal condition or in a persistent vegetative state, serves only to prolong the dying process.
“Persistent Vegetative State” – A permanent, irreversible condition of unconsciousness in which voluntary action or cognitive behavior of any kind is absent.
“Terminal Condition” – An irreversible condition, caused by injury, disease, or illness, which is incurable and which, without the administration of life-sustaining treatment, will, in the opinion of the attending physician, result in death within a reasonable period of time.
3. APPOINTMENT OF HEALTH CARE AGENT
3.1 Designation. The Principal hereby appoints [PRIMARY AGENT NAME], whose address is [PRIMARY AGENT ADDRESS] and phone [PRIMARY AGENT PHONE], as Agent.
3.2 Alternate Agents.
(a) First Alternate: [FIRST ALTERNATE NAME], address [ ], phone [ ].
(b) Second Alternate: [SECOND ALTERNATE NAME], address [ ], phone [ ].
3.3 Grant of Authority. Subject to Sections 3.4–3.7, the Agent may make any and all health-care decisions the Principal could make, including decisions to consent to, refuse, or withdraw treatment; admit or discharge from health-care facilities; and sign documents required to obtain or withhold treatment.
3.4 Priority of Decision-Makers. During the Principal’s incapacity, health-care providers shall follow the Agent’s instructions over those of any other person, except as otherwise required by law.
3.5 Scope Limitations.
(a) Mental Health Treatment: [INCLUDE / OMIT] authority to consent to psychotropic medication or electro-convulsive therapy.
(b) Autopsy Authorization: [AUTHORIZE / DO NOT AUTHORIZE].
(c) Disposition of Remains: [AUTHORIZE AGENT / RESERVE TO FAMILY].
3.6 Nomination of Guardian. If a court deems a guardian necessary, the Agent nominated in Section 3.1 shall serve as first nominee.
3.7 Duration. Authority granted herein remains effective until revoked pursuant to Section 7.1.
4. LIVING WILL DIRECTIVES
4.1 Statement of Intent. These instructions are an expression of the Principal’s legal right to accept or refuse medical or surgical treatment and shall be honored by health-care providers pursuant to A.R.S. § 36-3203.
4.2 General Instructions.
(a) Pain Relief. The Principal desires adequate pain relief and comfort even if such measures may hasten death.
(b) Artificial Nutrition & Hydration.
[ ] I refuse artificial nutrition and hydration if I am in a terminal condition or persistent vegetative state.
[ ] I desire artificial nutrition and hydration unless it will: (i) only prolong the dying process; or (ii) cause undue suffering.
(c) Cardiopulmonary Resuscitation (CPR).
[ ] If I have a valid Prehospital Medical Care Directive (Do-Not-Resuscitate), providers shall comply therewith.
[ ] Absent a DNR, I consent to CPR unless two physicians determine it will not restore meaningful quality of life.
(d) Mechanical Ventilation.
[ ] Refuse. [ ] Accept. [ ] Accept trial period of [NUMBER] days.
(e) Dialysis.
[ ] Refuse. [ ] Accept. [ ] Accept trial period of [NUMBER] days.
4.3 Pregnancy. If I am pregnant, I direct that life-sustaining treatment be provided if required by Arizona law to maintain the pregnancy.
4.4 Special Provisions.
[INSERT any religious, cultural, or personal instructions (e.g., Sabbath observance, dietary laws, blood transfusion refusal).]
5. ORGAN, TISSUE, AND BODY DONATION (OPTIONAL)
5.1 Anatomical Gifts. Upon my death, I make the following gifts pursuant to A.R.S. § 36-841 et seq.:
[ ] Any needed organs/tissues for transplantation or therapy.
[ ] Specific gift of _____.
[ ] No anatomical gifts.
5.2 Whole-Body Donation.
[ ] I donate my body for medical education or research to [PROGRAM NAME].
[ ] I do not wish to donate my body.
6. HIPAA AUTHORIZATION
6.1 Authorization. In accordance with 45 C.F.R. § 164.508(c), I authorize any covered entity to disclose Protected Health Information to my Agent to the extent necessary to make informed health-care decisions. This authorization survives my incapacity and terminates at the earlier of (a) my written revocation or (b) two years after my death.
6.2 Redisclosure Warning. Information disclosed pursuant to this authorization may be subject to redisclosure and no longer protected under HIPAA.
7. REVOCATION & AMENDMENT PROCEDURES
7.1 Revocation. This Directive may be revoked at any time by:
(a) A signed, dated writing expressing intent to revoke;
(b) Oral expression of intent to revoke in the presence of a witness age eighteen (18) or older;
(c) Destruction of the original document; or
(d) Execution of a subsequent directive.
7.2 Automatic Termination. Appointment of spouse as Agent is automatically revoked upon legal dissolution of marriage, unless expressly reaffirmed thereafter.
7.3 Amendment. The Principal may amend this Directive by a signed, dated writing that complies with witnessing or notarization requirements in Section 11.
8. RELIANCE, INDEMNIFICATION & LIABILITY CAPS
8.1 Good-Faith Reliance. Any health-care provider, institution, or individual acting in good faith reliance upon this Directive, or upon the oral instructions of the Agent, shall be protected to the fullest extent permitted by A.R.S. § 36-3205 from civil or criminal liability.
8.2 Indemnification. The Principal’s estate shall indemnify and hold harmless any health-care provider or facility that follows this Directive in good faith.
8.3 Liability Cap. To the maximum extent permitted by law, liability of any Agent acting in good faith and without gross negligence shall be limited to actual damages directly caused by willful misconduct. No consequential, punitive, or exemplary damages shall be recoverable.
9. GOVERNING LAW & DISPUTE RESOLUTION
9.1 Governing Law. This Directive shall be governed by and construed in accordance with the laws of the State of Arizona.
9.2 Injunctive Relief. Because health-care decisions are time-sensitive, the parties recognize that injunctive or declaratory relief may be the only adequate remedy for breach or threatened breach of this Directive.
[// GUIDANCE: Arbitration, jury waiver, and forum-selection clauses are typically unnecessary for a living will and are therefore omitted.]
10. GENERAL PROVISIONS
10.1 Severability. If any provision of this Directive is held invalid, the remaining provisions shall remain in full force to the extent feasible.
10.2 Copies. Photocopies, facsimiles, or electronically signed counterparts of this Directive shall have the same effect as the original.
10.3 Integration. This document constitutes the entire advance directive of the Principal and supersedes all prior instruments concerning the subject matter herein.
10.4 Witness Eligibility. No witness may be: (a) the Agent or alternate Agent; (b) related to the Principal by blood, marriage, or adoption; (c) entitled to any portion of the Principal’s estate; (d) directly involved in the Principal’s health-care; or (e) an employee of a provider currently caring for the Principal, unless the employee is unrelated and acting solely as a notary or in a non-decision-making capacity. See A.R.S. § 36-3223(D).
11. EXECUTION, WITNESS, AND NOTARIZATION
11.1 Principal’s Signature.
I, the Principal, have read and understand this Directive. I am emotionally and mentally competent to execute it and do so voluntarily.
Signature: ____ Date: __
Printed Name: _______
11.2 Statement of Witness — Option A (Two Witnesses).
We declare that the Principal is personally known to us, appears to be of sound mind, and signed or acknowledged this Directive in our presence and that we are not disqualified witnesses under Section 10.4.
Witness #1 Signature: ____ Date: ___
Printed Name: _____
Address: _____
Witness #2 Signature: ____ Date: ___
Printed Name: _____
Address: _____
11.3 Notarial Acknowledgment — Option B (Single Notary).
State of Arizona )
County of __ )
On this _ day of _, 20_, before me, the undersigned Notary Public, personally appeared [PRINCIPAL NAME], personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to this Directive, and acknowledged executing the same for the purposes therein contained.
Notary Public Signature: ____
Printed Name: _____
My Commission Expires: ______
[Seal]
[// GUIDANCE: Attach supplementary forms such as a Prehospital Medical Care Directive (DNR) or Mental Health Care Power of Attorney if desired. Provide executed copies to the Principal’s physician, Agent, and relevant health-care facilities, and consider registering online with the Arizona Advance Directive Registry.]