Living Will Form
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INITIAL box if you agree to have
this advance directive submitted to the WV e-Directive
Last Name/First/ Middle
Address
Registry, and released to treating health care providers.
City/State/Zip
Complete information to RIGHT.
REGISTRY FAX: 844-616-1415
Date of Birth (mm/dd/yyyy) _______/_______/_________
M__ F___
Last 4 SSN ___ ___ ___ ___ Gender
STATE OF WEST VIRGINIA
LIVING WILL
The Kind of Medical Treatment I Want and Don't Want
If I Have a Terminal Condition or Am In a Persistent Vegetative State
Living will made this
day of
(month, year).
I,
, being of sound mind, willfully and voluntarily declare
that I want my wishes to be respected if I am very sick and not able to communicate my wishes
for myself. In the absence of my ability to give directions regarding the use of life-prolonging
medicalintervention, it is my desire that my dying shall not be prolonged under the following
circumstances:
If I am very sick and not able to communicate my wishes for myself and I am certified by one physician
who has personally examined me, to have a terminal condition or to be in a persistent vegetative state (I
am unconscious and am neither aware of my environment nor able to interact with others,) I direct that
life-prolonging medical intervention that would serve solely to prolong the dying process or maintain me
in a persistent vegetative state be withheld or withdrawn. I want to be allowed to die naturally and only
be given medications or other medical procedures necessary to keep me comfortable. I want to receive as
much medication as is necessary to alleviate my pain.
I give the following SPECIAL DIRECTIVES OR LIMITATIONS: (Comments about tube feedings,
breathing machines, cardiopulmonary resuscitation, dialysis, and mental health treatment may be placed
here. My failure to provide special directives or limitations does not mean that I want or refuse certain
treatments.)
It is my intention that this living will be honored as the final expression of my legal right to refuse medical
or surgical treatment and accept the consequences resulting from such refusal.
I understand the full import of this living will.
____________________________________________
_____________________________________
Signed
Date
Address
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