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: ________________________________