Statutory Declaration in Conformance with Arizona Medical Treatment Decision Act, AZ. REV. STAT. 36-3202
DECLARATION OF __________________
Declaration made this __________ day of ________________ 20________. I, ______________, being of sound mind, willfully and artificially prolonged under the circumstances set forth below and declare that:
If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two physicians who have personally examined me, one of whom is my attending physician, and the physicians have determined that my death will occur unless life-sustaining procedures are used and if the application of life-sustaining procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, food or fluids or the performance of any medical procedures deemed necessary to provide me with comfort care.
In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this declaration shall be honored by my family and physicians as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.
I understand the full import of this declaration and I have the emotionally and mental capacity to make this declaration.
________________________________________
City of residence: _____________
County of residence: ___________
State of residence: ____________
Date: ________________________________
The Declarant has been personally known to me and I believe him or her to be of sound mind.
Witness _________________________________________________
Witness _________________________________________________
Date: _________________________
Statutory Declaration in Conformance with Arizona Medical Treatment Decision Act, AZ. REV. STAT. 36-3202
Review List
This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in Arizona. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.
- Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.
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