Fillable Statutory Advance Directive (Page 2 of 8) in pdf

Instructions for Completing the Directive:

This directive is written in two parts. While it is best if you fill out the whole document,

you may choose to complete only Section I, leaving just a statement of your values and wishes.

Or you may complete only Section II, just naming someone to speak for you. However, this may

leave your family and others without any evidence to support your wishes in the future, or leave

them unsure who is to make decisions and speak for you. Thus, omitting either section may

cause your loved ones difficulty if they must eventually make medical choices in your behalf.

So, you are strongly encouraged to complete the entire directive.

To complete the document, you should initial in the underlined spaces provided beside all

the questions that are asked, and fill in any blank lines as directed. Feel free to write “No,”

“None,” or “Does Not Apply” in areas that would otherwise be left blank.

SECTION I:

LIVING WILL DECLARATION

and Personal Instructions

(State C ode, Title16: Art.36: C h.4:§16-36-4-1 to §16-36-4-21)

1. INTRODUCTION: There are two statutory versions of the Indiana Living Will, and both are

included here. The first is designed primarily to refuse “life prolonging procedures” in

the event an individual has been diagnosed with a terminal condition. The second is for

use by those wanting to request continued treatment in a terminal condition.

A terminal condition is defined as “a condition caused by injury, disease, or

illness from which, to a reasonable degree of medical certainty: 1) there can be no

recovery; and 2) death will occur from the terminal condition within a short period of

time without the provision of life prolonging procedures”

. Life-prolonging

(§16-36-4-5)

procedures are defined as, “any medical procedure, treatment, or intervention that does

the following: 1) uses mechanical or other artificial means to sustain, restore, or

supplant a vital function; 2) serves to prolong the dying process”

. The term

(§16-36-4-1)

does not include the “provision of any medical procedure or medication necessary to

provide comfort care or to alleviate pain”

(§16-36-4-1)

Finally, there is specific provision made in the statutes for adding personal

information to your Living Will document

. Doing so can further aid those

(§16-36-4-9)

making any future decisions about your care. To this end, Lifecare staff have produced a

“Living Will Addendum” which includes information that the overwhelming majority of

the public has pronounced as being of importance to them. Completing the addendum

can be of significant importance to you and those you love, should further information

about your health care wishes be needed.

OPTION A: LIVING WILL DECLARATION

(Terminal Treatment Refusal):

(Complete this section only if you wish to refuse life-prolonging medical treatment if you become

terminally ill. If you know that you want to request terminal treatment, skip to the “Life-

Prolonging Procedures Declaration,” in the section which follows)

Statutory Advance Directive Page 2

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