This Living Will Declaration is a document indicating the wishes of a patient should they become unable to make medical and other healthcare decisions. It will state an individual’s choice regarding the use of life sustaining or life support procedures. This document in its draft form contains numerous of the standard clauses commonly used in these types of agreements but it can be customized to fit the needs of any individual seeking to establish a living will.
This Living Will Declaration is a document indicating the wishes of a patient should they become unable to make medical and other healthcare decisions. It will state an individual’s choice regarding the use of life sustaining or life support procedures. This document in its draft form contains numerous of the standard clauses commonly used in these types of agreements but it can be customized to fit the needs of any individual seeking to establish a living will. LIVING WILL DECLARATION I, ________________, being of sound mind and body, after careful consideration and thought, freely and intentionally make this revocable declaration to state that if I should become unable to make decisions as to life sustaining or life support procedures, then I request that my dying shall not be delayed, prolonged, or extended artificially by medical science or life sustaining medical procedures in accordance with my wishes as set forth in this Living Will. It is my intent in the execution of these instructions that they be carried out as fully as is feasible by my physicians, family and friends, and legal representatives. If I am unable to make decisions regarding the use of medical life sustaining or life support systems and/or procedures, and if I have a sickness, illness, disease, injury or condition which has been diagnosed by two (2) licensed medical doctors or physicians who have personally examined me with either terminal or incurable certified to be terminal illness; a condition from which there is no reasonable hope of my recovery to a meaningful quality of life; has rendered me in a persistent vegetative state; a condition of extreme mental deterioration; or permanently unconscious, I request that all medical life sustaining or life support systems and procedures shall be withdrawn except as explicitly set forth in this Living Will. Nothing in this Living Will shall be interpreted as a prohibition of the administration of pain relieving medications or procedures or other relevant palliative care provided even if such treatment may shorten my life or have other adverse effects. I am also stating the following additional instructions so that my Living Will is as clear as possible: 1. In the event that I require artificial resuscitation i.e. CPR, I do/do not wish artificial resuscitation to be performed. [Instruction: Clearly indicate your choice] 2. In the event that I require an intravenous feeding tube, I do/ do not wish an intravenous feeding tube to be utilized. [Instruction: Clearly indicate your choice] 3. In the event that I require a life sustaining surgery, I do/ do not wish such surgery to be performed. 4. _______________________________________________________________ ________________ I certify that my family, the medical facility, and any doctors, nurses and other medical personnel involved in my care shall have no civil or criminal liability for following the instructions as set forth in this Living Will. © Copyright 2011 Docstoc Inc. 2 If any provision of this Living Will is deemed unenforceable or considered invalid under my current state of residence or state laws where I may be obtaining treatment, all other provisions are to be deemed enforceable and valid and all terms are to be considered severable. I reserve the right to revoke all or part of this Living Will at any time. Such revocation may be via oral statement witnessed by two witnesses or by writing, which is signed by a witness and/or notary. [Instruction: Verify whether your jurisdiction permits a revocation via oral statement] A copy of this Living Will shall have the same force and effect as the original so long as all appropriate signatures are present. I have read and understand this Living Will, and I am freely and voluntarily signing it on ____________________ in the presence of witnesses. Signed: ___________________________________ Street Address: _____________________________ County: ___________________________________ City and State: _____________________________ I certify that I am at least 18 years of age, mentally competent and not related to Declarant by blood, marriage or adoption, nor do I stand to inherit any of Declarant’s estate in the event of his/her demise, by any means including will, trust or prevailing laws. I do not stand to benefit in any other way from the demise of Declarant nor am I directly responsible for the health, medical care or general well being of Declarant. I further certify that I witnessed Declarant review and sign this Living will of his/her own free and voluntary will and I am not aware that Declarant has been forced under duress or otherwise to sign this Living Will. Witness signature: _______________________________ Print Name:____________________________________ Street Address: _____________________________ County: ___________________________________ City and State: _____________________________ © Copyright 2011 Docstoc Inc. 3 Notary Acknowledgment State of _______________________ County of _____________________ This instrument was acknowledged before me on _____________________ by [Declarant] , the Declarant herein, on oath stating that the Declarant is over the age of 18, has fully read and understands the above and foregoing Living Will, and that the Declarant's signing and execution of same is voluntary, without coercion, and is intentional. __________________________ __ Notary Public My commission or appointment expires: _______________ [Seal] © Copyright 2011 Docstoc Inc. 4
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