Health Care Advance Directives, Living Will, Designation Of Health Care Surrogate Template, Uniform Donor Form (Page 5 of 9) in pdf

Living Will

Declaration made this _____ day of ________________, 2____, I, ____________________________,

willfully and voluntarily make known my desire that my dying not be artificially prolonged under the

circumstances set forth below, and I do hereby declare that, if at any time I am mentally or physically

incapacitated and

_____(initial) I have a terminal condition,

or _____(initial) I have an end-stage condition,

or _____(initial) I am in a persistent vegetative state,

and if my attending or treating physician and another consulting physician have determined that there is

no reasonable medical probability of my recovery from such condition, I direct that life-prolonging

procedures be withheld or withdrawn when the application of such procedures would serve only to

prolong artificially the process of dying, and that I be permitted to die naturally with only the

administration of medication or the performance of any medical procedure deemed necessary to provide

me with comfort care or to alleviate pain.

I do ___, I do not ___ desire that nutrition and hydration (food and water) be withheld or withdrawn when

the application of such procedures would serve only to prolong artificially the process of dying.

It is my intention that this declaration be honored by my family and physician as the final expression of

my legal right to refuse medical or surgical treatment and to accept the consequences for such refusal.

In the event I have been determined to be unable to provide express and informed consent regarding the

withholding, withdrawal, or continuation of life-prolonging procedures, I wish to designate, as my

surrogate to carry out the provisions of this declaration:

Name ________________________________________________________

Street Address _________________________________________________

City _______________________ State _____________ Phone ___________

I understand the full import of this declaration, and I am emotionally and mentally competent to make this

declaration.

Additional Instructions (optional): ______________________________________________________

__________________________________________________________________________________

(Signed) ___________________________________________________

Witness _____________________________

Street Address ________________________

City _____________________ State _______

Phone _________________

Phone ________________

At least one witness must not be a husband or wife or a blood relative of the principal.

Health Care Advance Directives, Living Will, Designation Of Health Care Surrogate Template, Uniform Donor Form Page 5