Illinois Living Will Declaration Template (Page 4 of 8) in pdf

I want my life to be prolonged and I want life-sustaining treatment to be provided or

continued unless I am in a coma which my attending physician believes to be irreversible,

in accordance with reasonable medical standards at the time of reference. If and when I

have suffered irreversible coma, I want life-sustaining treatment to be withheld or

discontinued. Initialed ________

I want my life to be prolonged to the greatest extent possible without regard to my

condition, the chances have for recovery or the cost of the procedures. Initialed ________

(THIS POWER OF ATTORNEY MAY BE AMENDED OR REVOKED BY YOU IN

THE MANNER PROVIDED IN SECTION 4-6 OF THE ILLINOIS "POWERS OF

ATTORNEY FOR HEALTH CARE LAW" (SEE THE END OF THIS FORM).

ABSENT AMENDMENT OR REVOCATION, THE AUTHORITY GRANTED IN

THIS POWER OF ATTORNEY WILL BECOME EFFECTIVE AT THE TIME THIS

POWER IS SIGNED AND WILL CONTINUE UNTIL YOUR DEATH, AND

BEYOND IF ANATOMICAL GIFT, AUTOPSY OR DISPOSITION OF REMAINS IS

AUTHORIZED, UNLESS A LIMITATION ON THE BEGINNING DATE OR

DURATION IS MADE BY INITIALING AND COMPLETING EITHER OR BOTH OF

THE FOLLOWING:)

3.( ) This power of attorney shall become effective on ___________________________

(insert a future date or event during your lifetime, such as court determination of your

disability, when you want this power to first take effect)

4. ( ) This power of attorney shall terminate on _________________________________

(insert a future date or event, such as court determination of your disability, when you

want this power to terminate prior to your death)

(IF YOU WISH TO NAME SUCCESSOR AGENTS, INSERT THE NAMES AND

ADDRESSES OF SUCH SUCCESSORS IN THE FOLLOWING PARAGRAPH.)

5. If any agent named by me shall die, become incompetent, resign, refuse to accept the

office of agent or be unavailable, I name the following (each to act alone and

successively, in the order named) as successors to such agent:

______________________________________

For purposes of this paragraph 5, a person shall be considered to be incompetent if and

while the person is a minor or an adjudicated incompetent or disabled person or the

person is unable to give prompt and intelligent consideration to health care matters, as

certified by a licensed physician.

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Illinois Living Will Declaration Template Page 4