Fillable State Of Ohio - Living Will Declaration Template printable pdf download

State of Ohio

Living Will Declaration

_____________________________

(Print Full Name)

________________________

(Birth Date)

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.

DEFINITIONS

Several legal and medical terms are used in this document. For convenience they are explained below.

Anatomical gift means a donation of all or part of a human body to take effect upon or after death.

Artificially or technologically supplied nutrition or hydration means the providing of food and fluids through intravenous or tube

“feedings.”

Cardiopulmonary resuscitation or CPR means treatment to try to restart breathing or heartbeat. CPR may be done by breathing into

the mouth, pushing on the chest, putting a tube through the mouth or nose into the throat, administering medication, giving electric

shock to the chest, or by other means.

Declarant means the person signing this document.

Donor Registry Enrollment Form means a form that has been designed to allow individuals to specifically register their wishes

regarding organ, tissue and eye donation with the Ohio Bureau of Motor Vehicles Donor Registry.

Do Not Resuscitate or DNR Order means a medical order given by my physician and written in my medical records that

cardiopulmonary resuscitation or CPR is not to be administered to me.

Health care means any medical (including dental, nursing, psychological, and surgical) procedure, treatment, intervention or other

measure used to maintain, diagnose or treat any physical or mental condition.

Health Care Power of Attorney means another document that allows me to name an adult person to act as my agent to make health

care decisions for me if I become unable to do so.

Life-sustaining treatment means any health care, including artificially or technologically supplied nutrition and hydration, that will

serve mainly to prolong the process of dying.

Living Will Declaration or Living Will means this document that lets me specify the health care I want to receive if I become

terminally ill or permanently unconscious and cannot make my wishes known.

Permanently unconscious state means an irreversible condition in which I am permanently unaware of myself and my surroundings.

My physician and one other physician must examine me and agree that the total loss of higher brain function has left me unable to feel

pain or suffering.

Terminal condition or terminal illness means an irreversible, incurable and untreatable condition caused by disease, illness or injury.

My physician and one other physician will have examined me and believe that I cannot recover and that death is likely to occur within

a relatively short time if I do not receive life-sustaining treatment.

[Instructions and other information to assist in completing this document are set forth within

brackets and in italic type.]

State Of Ohio - Living Will Declaration Template