Kentucky Will To Live Form Living Will Directive
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5Kentucky Will to Live Form
Living Will Directive
My wishes regarding life-prolonging treatment and artificially provided nutrition and hydration
to be provided to me if I no longer have decisional capacity, have a terminal condition, or
become permanently unconscious have been indicated by checking and initialing the appropriate
lines below. By checking and initialing the appropriate lines, I specifically:
Designate
as
(initial)
(name of surrogate)
my health care surrogate to make any health care decisions for me in accordance with this
directive when I no longer have decisional capacity.
If
(name of surrogate) refuses or is not able to act
for me, I designate
(name of alternate
surrogate) as my health care surrogate.
If none of the above are willing to act for me, I designate
(name of second alternate surrogate) as my health care surrogate.
Any prior designation is revoked.
If I do not designate a surrogate, the following are my directions to my attending physician. If I
have designated a surrogate, my surrogate shall comply with my wishes as indicated below:
Direct that treatment be withheld or withdrawn, and that I be
permitted to die naturally with only the administration of medication or the
performance of any medical treatment deemed necessary to alleviate my pain.
DO NOT authorize that life-prolonging treatment be withheld or
(initial)
withdrawn.
Authorize the withholding or withdrawal of artificially provided
food, water, or other artificially provided nourishment or fluids.
DO NOT authorize the withholding or withdrawal of artificially
(initial)
provided food, water, or other artificially provided nourishment or
fluids.
Authorize my surrogate, designated above, to withhold or
withdraw artificially provided nourishment or fluids, or other
treatment if the surrogate determines that withholding or
withdrawing is in my best interest; but I do not mandate that
withholding or withdrawing.
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