Living Will Form

Living Will Sample The following sample of a living will is just what its name implies. It is nothing more than a possible sample that may be used. Individuals preparing a living will may include other directions or be more or less specific. DECLARATION i, name of declarant , being of sound mind, willfully and voluntarily make this declaration to be followed if I become incompetent. This declaration reflects my firm and settled commitment to refuse life-sustaining treatment under the circumstances indicated below. I direct my attending physician to withhold or withdraw life-sustaining treatment that serves only to prolong the process of my dying, if I should be in a terminal condition or in a state of permanent unconsciousness. I direct that treatment be limited to measures to keep me comfortable and to relieve pain, including any pain that might occur by withholding or withdrawing life-sustaining treatment. In addition, if I am in the condition described above, I feel especially strongly about the following forms of treatment: I ( )do ( )do not want cardiac resuscitation. I ( )do ( )do not want mechanical respiration. I ( )do ( )do not want tube feeding or any other artificial or invasive form of nutrition (food) or hydration (water). I ( )do ( )do not want blood or blood products. I ( )do ( )do not want any form of surgery or invasive diagnostic tests. I ( )do ( )do not want kidney dialysis. I ( )do ( )do not want antibiotics. I realize that if I do not specifically indicate my preference regarding any of the forms of treatment listed previously, I may receive that form of treatment. Other instructions: I ( )do ( )do not want to designate another person as my surrogate to make medical treatment decisions for me if I should be incompetent and in a terminal condition or in a state of permanent unconsciousness. Name and address of surrogate (if applicable): Name and address of substitute surrogate (if surrogate designated above is unable to serve): I made this declaration on the Declarant's signature: Declarant's address: day of (month, year). The declarant or the person on behalf of and at the direction of the declarant knowingly and voluntarily signed this writing by signature or mark in my presence. Witness' signature: Witness' address: Witness' signature: Witness' address: Any writing that meets the requirements of this article may be used to create a living will. A person may write and use a living will without writing a health care power of attorney or may attach a living will to the person's health care power of attorney. If a person has a health care power of attorney, the agent must make health care decisions that are consistent with the person's known desires and that are medically reasonable and appropriate. A person can, but is not required to, state the person's desires in a living will. The following form is offered as a sample only and does not prevent a person from using other language or another form: Living Will (Some general statements concerning your health care options are outlined below. If you agree with one of the statements, you should initial that statement. Read all of these statements carefully before you initial your selection. You can also write your own statement concerning life-sustaining treatment and other matters relating to your health care. You may initial any combination of paragraphs 1, 2, 3 and 4 but if you initial paragraph 5 the others should not be initialed.) _____ 1. If I have a terminal condition I do not want my life to be prolonged and I do not want lifesustaining treatment, beyond comfort care, that would serve only to artificially delay the moment of my death. _____ 2. If I am in a terminal condition or an irreversible coma or a persistent vegetative state that my doctors reasonably feel to be irreversible or incurable, I do want the medical treatment necessary to provide care that would keep me comfortable, but I do not want the following: _____ (a) Cardiopulmonary resuscitation, for example, the use of drugs, electric shock and artificial breathing. _____ (b) Artificially administered food and fluids. _____ (c) To be taken to a hospital if at all avoidable. _____ 3. Notwithstanding my other directions, if I am known to be pregnant, I do not want lifesustaining treatment withheld or withdrawn if it is possible that the embryo/fetus will develop to the point of live birth with the continued application of life-sustaining treatment. _____ 4. Notwithstanding my other directions I do want the use of all medical care necessary to treat my condition until my doctors reasonably conclude that my condition is terminal or is irreversible and incurable or I am in a persistent vegetative state. _____ 5. I want my life to be prolonged to the greatest extent possible. Other or Additional Statements of Desires I have _____ I have not _____ attached additional special provisions or limitations to this document to be honored in the absence of my being able to give health care directions. Sample Living Will Form Each of the fifty states have some law regarding the ability of patients to make decisions about their medical care before the need for treatment arises through the use of advance directives. The great majority of states allow for patients to draft living wills that set forth the type and duration of medical care that they wish to receive should they become unable to communicate those wishes on their own. Although the law in each state will vary as to what can be included in a living will, the following sample can provide a general overview of what one may look like, and what information may be included. Of course, before assuming that this sample will be sufficient for your purposes, you should check the law in your jurisdiction or have an attorney review your advance directives. In some states, however, an unapproved document may have some persuasive effect. LIVING WILL DECLARATION OF _______________ To my family, doctors, hospitals, surgeons, medical care providers, and all others concerned with my care: I, ______________________________, being of sound mind and rational thought willfully and voluntarily make this declaration to be followed if I become incompetent or incapacitated to the extent that I am unable to communicate my wishes, desires and preferences on my own. This declaration reflects my firm, informed, and settled commitment to refuse life-sustaining medical care and treatment under the circumstances that are indicated below. This declaration and the following directions are an expression of my legal right to refuse medical care and treatment. I expect and trust the above-mentioned parties to regard themselves as legally and morally bound to act in accordance with my wishes, desires, and preferences. The above-mentioned parties should therefore be free from any legal liabilities for having followed this declaration and the directions that it contains. DIRECTIONS 1. I direct my attending physician or primary care physician to withhold or withdraw life-sustaining medical care and treatment that is serving only to prolong the process of my dying if I should be in an incurable or irreversible mental or physical condition with no reasonable medical expectation of recovery. 2. I direct that treatment be limited to measures which are designed to keep me comfortable and to relieve pain, including any pain which might occur from the withholding or withdrawing of life-sustaining medical care or treatment. 3. I direct that if I am in the condition described in item 1, above, it be remembered that I specifically do not want the following forms of medical care and treatment: A. B. C. D. _____________________________________ _____________________________________ _____________________________________ _____________________________________ 4. I direct that if I am in the condition described in item 1, above, it be remembered that I specifically do want the following forms of medical care and treatment: A. B. C. D. _____________________________________ _____________________________________ _____________________________________ _____________________________________ 5. I direct that if I am in the condition described in item 1, above, and if I also have the condition or conditions of ____________________, that I receive the following medical care and treatment: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ This Living Will Declaration expresses my firm wishes, desires, and preferences and the fact that I may have executed a form specified by the law of the State of _____________, may not be used a limiting or contradicting this Living Will Declaration, which is an expression of both my common law and constitutional rights. I make this Living Will Declaration the _______ day of __________, 20____. ________________________________________________ Declarant’s Signature ________________________________________________ ________________________________________________ ________________________________________________ Declarant’s Address WITNESS STATEMENTS I declare that the person who signed or acknowledged this document is personally known to me, that he/she signed or acknowledged this Living Will Declaration in my presence, and that he/she appears to be of sound mind and under no duress, fraud, or undue influence. ________________________________________________ Witnesses’ Signature ________________________________________________ Witnesses’ Printed Name ________________________________________________ ________________________________________________ Witnesses’ Address I declare that the person who signed or acknowledged this document is personally known to me, that he/she signed or acknowledged this Living Will Declaration in my presence, and that he/she appears to be of sound mind and under no duress, fraud, or undue influence. ________________________________________________ Witnesses’ Signature ________________________________________________ Witnesses’ Printed Name ________________________________________________ ________________________________________________ Witnesses’ Address NOTARIZATION STATE OF _______________________, COUNTY OF ___________________ Subscribed and sworn to before me his ________ day of ________, 20_____. _______________________________ Signature of Notary Public My commission expires: ________________________________