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End of Life Care Planning

Where to Start?

End-of-life care planning can feel daunting, confusing, or even challenging for some people. A common thing we hear from people in our community is that they are unsure where to begin.

We are here to help!

We’ve outlined a six-step process for completing your advance care planning, with resources, tips, and personalized assistance along the way!

Jump to a Step!

Step 1:

Identify Your Trusted People

Step 2:

What’s Important to You?

Step 3:

Have the Conversation

Step 4:

Write it (All) Down

Step 5:

Save and Share Your Documents

Step 6:

Review and Revise

Step 1

Identify Your Trusted People

The first step to advance care planning is to decide who you want to speak for you in the event of a medical emergency.

This person, referred to as a healthcare proxy, surrogate, representative, or simply “your person”, is an advocate for your wishes. They understand what is important to you, know the types of care you’d like to receive, and can make decisions for you when you cannot.

Who comprises your personal committee of trusted people? You can choose more than one! These can be family members, friends, clergy, anyone whom you trust to follow your wishes. The identified representative will only speak for you if you cannot, as in instances of medical incapacitation. 

Sometimes the easiest way to choose a person is to think about who in your life you wouldn’t want to speak for you!

Below you will find some helpful resources for choosing your person.


Step 2

What’s Important to You?

After choosing your healthcare proxy, we recommend taking time to think about what matters most to you.

Thinking about your own end of life can be challenging, and for many people this is a hurdle that they struggle to pass, but it doesn’t have to be that way. Start by thinking about the things that matter to you right now. 

Do you enjoy spending time with your family? Do you enjoy being outside whenever possible? Is listening to music to start your day important to you? How do you enjoy spending your time before bed in the evening?

The things that are important to you in your every day life will help you figure out how you would like your care at the end of your life.

Below you will find some helpful resources for this step in the process.


Step 3

Have the Conversation

Once you’ve chosen your person and begun thinking about your end-of-life care, the next step is to have the conversation.

Sounds easy, right?

While we understand that talking about end of life is something we are not conditioned to do easily, it is our firm belief that talking about end of life actually enhances our lives. The more we talk about it, the easier it becomes!

Having the conversation will allow your chosen proxy to better advocate for your wishes when necessary. While having a completed advance directive will help guide the kinds of treatment you’d like to receive, ensuring your healthcare proxy understands your advance directive and your wishes will help them to answer questions from healthcare professionals in the ways that best align with your desired care.

There are numerous resources to help guide you through having the conversation. We’ve included a few of our favorites below!


Step 4

Write It (All) Down

Now comes the really fun part: paperwork!

This step is all about completing your end-of-life care planning forms. This part can be confusing, so we’ve tried to break it down as easily as we can.

There are a few pathways you can take, because there are different forms that may appeal to different people. Don’t worry, all the forms below are legally recognized in the state of Arizona.

Our Partnership recommends the Five Wishes Pathway for its ease and person-first approach to the process. Five Wishes is an advance directive that includes a Living Will and the Medical Power of Attorney form. In Arizona you will need to complete a separate Mental Health Care Power of Attorney form, which you will find below!

The second pathway includes separate forms for the Living Will, Medical Power of Attorney, and Mental Health Care Power of Attorney, all included below.

Additionally, our Partners provide free community events and support to guide you through the advance care planning process, including education and personalized assistance with completing your documents. To register for an upcoming event, view our events calendar:

Five Wishes Pathway

DNR – Do Not Resuscitate

This optional form informs medical personnel that you do not want CPR to be started if you stop breathing. To complete this form, talk to your healthcare provider. Click here for more information.

State of Arizona Forms Pathway

DNR – Do Not Resuscitate

This optional form informs medical personnel that you do not want CPR to be started if you stop breathing. To complete this form, talk to your healthcare provider. Click here for more information.

POLST – Portable Medical Order

This optional form helps patients get the medical treatments they want in an emergency, and avoid medical treatments they do not want, when they are seriously ill or frail. Click here for more information.

Step 5

Save and Share Your Documents

After you have completed all of your documents, the next step is to share and save your documents.

To make this easy, you should:

  • Give copies of your documents to all of your healthcare providers
  • Give a copy of your documents to your designated healthcare proxy or proxies
  • Store a copy (or copies) in your home
  • Upload a copy to the Arizona Healthcare Directives Registry which will allow healthcare providers across the state to access your wishes at a moment’s notice

Below you will find more information about how to store and share your documents.


Step 6

Review and Revise

You might be wondering “Can I change my mind?” 


It is recommended that you periodically review your documents and revise them whenever needed. We change our minds all the time, and advance care planning is no different!

When deciding when to update your documents, keep in mind the Six D’s:

  1. New Medical Diagnosis
  2. Decline in your health status
  3. After the Death of a close friend or loved one
  4. Divorce or relationship status change
  5. Every Decade
  6. Distance

Experiencing these life events can change a number of things in your documents, including whether you need new forms if you’ve moved to a different state, new healthcare proxies due to death or distance, and new perspectives after experiencing the death of a loved one.

Remember: You can update your documents at any time.

Additional Resources for Advance Care Planning