Sample Living Will
Declaration
(a) Execution - An individual of sound mind who is 18 years of age or older or who has graduated from high school or has married may execute at any time a declaration governing the initiation, continuation, withholding or withdrawal of life-sustaining treatment. The declaration must be signed by the declarant or by another on behalf of and at the direction of the declarant, and must be witnessed by two individuals each of whom is 18 years of age or older. A witness shall not be the person who signed the declaration on behalf of and at the direction of the declarant.
(b) Form - A declaration may but need not be in the following form and may include other specific directions, including, but not limited to, designation of another person to make the treatment decision for the declarant if the declarant is incompetent and is determined to be in a terminal condition or to be permanently unconscious.
DECLARATION
I, , 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 strong about the following forms of treatment.
[ ] do: [ ] do not want cardiac resuscitation.
[ ] do: [ ] do not want mechanical respiration.
[ ] do: [ ] do not want tube feeding or any other artificial or invasive form
of nutrition (food) or hydration (water).
[ ] do: [ ] do not want blood or blood products.
[ ] do: [ ] do not want any form of surgery or invasive diagnostic tests.
[ ] do: [ ] do not want kidney dialysis.
[ ] do: [ ] do not want antibiotics.
I realize that if I do not specifically indicate my preference regarding any of the forms of treatment listed above, 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:
Name and address of substitute surrogate (if surrogate designated above is unable to serve):
I [ ] do [ ] do not want to make an anatomical gift of all or part of my body, subject to the following limitations, if any:
I made this declaration on the day of , 2005.
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's signature: ________________________________________
Witness's address: _________________________________________
_________________________________________________________
Witness's signature: ________________________________________
Witness's address: _________________________________________
_________________________________________________________
(c) Invalidity of specific direction - Should any specific direction in the declaration be held to be invalid, the invalidity shall not offset other directions of the declaration which can be effected without the invalid direction.
(d) Medical record - A physician or other health care provider who is furnished a copy of the declaration shall make it a part of the declarant's medical record and, if unwilling to comply with the declaration, promptly so advise the declarant.
THIS SAMPLE LIVING WILL IS PROVIDED AS A PUBLIC SERVICE ONLY. USE OF THIS DOCUMENT, WITHOUT FIRST CONSULTING WITH AN ATTORNEY IS NOT ADVISABLE. PLEASE SCHEDULE AN APPOINTMENT WITH AN ATTORNEY TO DISCUSS ADVANCE HEALTH CARE DECLARATIONS AND MEDICAL DURABLE POWER OF ATTORNEY.
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