Living Will, Designation Of Health Care Surrogate, Uniform Donor Forms
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3Living 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be withheld or withdrawn when the application of such procedures would serve only to prolong artificially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I do ___, I do not ___ desire that nutrition and hydration (food and water) be withheld or withdrawn when the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 _____________________________
Witness _____________________________
Street Address ________________________
Street Address ________________________
City __________________ State_______
City _________________State_______
Phone _________________
Phone _________________
At least one witness must not be a husband or wife or a blood relative of the principal.
.
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