State Of Ohio - Living Will Template printable pdf download

Hospice of Dayton

324 Wilmington Ave.

Dayton, OH 45420

937 256 4490

State of Ohio Living Will

Declaration of ______________________________________,

(Name)

Date of Birth ________________________.

I state that this is my Ohio Living Will Declaration. I am of sound mind and not under or subject

to duress, fraud or undue influence. I am a competent adult who understands and accepts the

consequences of this action. I voluntarily declare my wish that my dying not be artificially

prolonged. If I am unable to give directions regarding the use of life-sustaining treatment when I

am in a terminal condition or a permanently unconscious state, I intend that this Living Will

Declaration be honored by my family and physicians as the final expression of my legal right to

refuse health care.

Health Care if I am in a terminal condition. If I am in a terminal condition and unable to make

my own health care decisions I direct that my physician shall:

1. Administer no life-sustaining treatment, including CPR and artificially or technologically

supplied nutrition or hydration; and

2. Withdraw such treatment, including CPR, if such treatment has started; and

3. Issue a Do Not Resuscitate Order and

4. Permit me to die naturally and take no action to postpone my death, providing me with

only that care necessary to make me comfortable and to relieve my pain.

Health Care if I am in a Permanently Unconscious State. If I am in a permanently

unconscious state, I direct that my physician shall:

Administer no life-sustaining treatment, including CPR, except for the provision of

artificially or technologically supplied nutrition or hydration unless, in the following

paragraph detailing Special Instructions, I have authorized its withholding or

withdrawal; and

Withdraw such treatment, including CPR, if such treatment has started; and

Issue a DNR Order and

Permit me to die naturally and take no action to postpone my death, providing me

with only that care necessary to make me comfortable and to relieve my pain.

Special instructions: By placing my initials at number 3 below, I specifically authorize my

physician to withhold or to withdraw artificially or technologically supplied nutrition or hydration

if:

I am in a permanently unconscious state; and

My physician and at least one other physician who has examined me have

determined, to a reasonable degree of medical certainty, that artificially or

technologically supplied nutrition and hydration will not provide comfort to me or

relieve my pain; and

I have placed my initials on this line: __________________

In the event my attending physician determines that life-sustaining treatment should be withheld

or withdrawn, my physician shall make a reasonable effort to notify those designated by law (my

guardian, spouse, adult children, parents or majority of adult siblings) or one of the following

persons in the following order of priority (You are not required to name anyone. Please cross

out any unused lines):

State Of Ohio - Living Will Template

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