Docstoc

Living Will Form - DOC - DOC

Document Sample
Living Will Form - DOC - DOC Powered By Docstoc
					                                    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                    day of                         (month, year).

Declarant's signature:

Declarant's address:

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 life-
sustaining 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 life-
sustaining 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: ________________________________

				
DOCUMENT INFO
Description: This is an example of living will form. This document is useful for creating living will.