Make sure that your family and your doctor know your wishes for end-of-life treatment in the event that you become physically or mentally incapacitated, with this Living Will form for the Yukon.
A Living Will is an advance medical directive. It allows you the opportunity to set out your wishes regarding what types of medical treatment you want or don't want, in the event that you are diagnosed with a terminal condition or are in a coma with no real chance of recovery. If you wish, you can also appoint someone as your proxy to give consent and make medical decisions on your behalf.
The form also includes:
- Declaration of Incapacity forms,
- information and instructions to help you complete the form.This Yukon Living Will form is a downloadable MS Word file, which is easy to fill in and print. No need to buy separate copies for each family member. You can use this form over again as often as you like.
LIVING WILL TO MY FAMILY, MY PHYSICIAN, MY LAWYER, MY CLERIC, TO ANY MEDICAL FACILITY IN WHOSE CARE I HAPPEN TO BE, AND TO ANY INDIVIDUAL WHO MAY BECOME RESPONSIBLE FOR MY HEALTH, WELFARE, OR AFFAIRS: Name: __________________________________________________ [give full name] Address: __________________________________________________ [give full address] _______________________, Yukon Date of birth: __________________ Phone: (_______) _________________ I, the above named maker of this Living Will, being of sound mind, and over the age of 16 years, request that you follow my wishes and execute this directive, to the best of your ability, in the event that I become unable to make health decisions for myself. 1. If at any time I should be certified by my attending physician and one (1) other physician who have both personally examined me to have a terminal condition or to be in a persistent vegetative state with no reasonable expectation of recovery, I would like my physician to: [Choose the appropriate option and delete the other.] Continue to use all available resources to keep me alive, if considered medically reasonable in the circumstances. Withhold or withdraw treatment that artificially prolongs the moment of my death, taking into account the specific instructions given below, and permit me to die naturally with only the administration of medication and care necessary to keep me comfortable and alleviate pain. 2. Specific Instructions: [optional - if there are none, state “None” below, and delete the balance of this paragraph. Otherwise, if there are certain treatments or procedures you do not want, specify them below and delete any that you DO WANT.] If I am in a terminal condition or in an irreversible coma or in a persistent vegetative state that my doctors reasonably feel to be irreversible or incurable, I DO NOT want the following: Cardiopulmonary resuscitation, for example, the use of drugs, electric shock and artificial breathing. Tube feeding. Hydration. Blood or blood products. Invasive surgery and tests. Antibiotics. To be taken to a hospital if at all avoidable, as it is my wish to be cared for at home if it is possible to do so. 3. In the absence of my ability to give directions regarding the use of such life sustaining procedures, it is my intention that this Living Will be honored by my family and physicians as the final expression of my wishes to refuse medical or surgical treatment and accept the consequences from that refusal. -2- 4. If I have been diagnosed as pregnant and that diagnosis is known to my physician, this Living Will has no effect during my pregnancy. 5. This Living Will is in effect until it is revoked, and I understand that I may revoke this Living Will at any time. 6. If I should become unable to communicate my instructions as stated above, I designate the following person as my proxy, to act on my behalf: Name: __________________________________________________ [give full name] Address: __________________________________________________ [give full address] _________________, Yukon Home Phone: (___) _
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