Living Will Declaration Form printable pdf download

Living Will Declaration

I, _______________________________________, hereby state my wishes about procedures to artificially prolong my dying (also called life-

Print Name

prolonging procedures) in certain situations.

If I am unable to make informed medical decisions for myself and I am found to be in any of the conditions that I note with my initials below, I

want life-prolonging procedures to be withheld or stopped if such procedures have little or no chance of curing me or helping me recover from

the condition, but would only serve to artificially prolong my dying. In other words, I want to be allowed to die naturally, with only treatments

that will keep me comfortable and relieve pain.

(Place your initials by every condition that you want this Living Will to apply to. If you do not place your initials in a blank and you are in that condition you

will receive life-prolonging procedures for that condition.)

_______ I have a condition caused by injury, disease or illness that is expected to cause death (also called a terminal condition)

_______ I am in a permanent state of unconsciousness (also called a permanent vegetative state)

_______ I have a condition caused by injury, disease or illness that has resulted in progressively severe and permanent deterioration (also called an

end-stage condition)

If I cannot eat or drink naturally (by mouth) and giving me food and water artificially would serve only to prolong my dying:

_______ I DO want

_______ I DO NOT want

________ food (nutrition)

_______ food (nutrition)

________ water (hydration)

_______ water (hydration)

In the event that I suffer cardiac or respiratory arrest (that is, I stop breathing or my heart stops beating):

_______ I DO want

_______ I DO NOT want

________ CPR (compressions/defibrillation/

resuscitation medications)

________ to be intubated (tube in lungs to help me breathe)

I give these directions after careful thought and in keeping with my convictions and beliefs. I expect my family, doctor, and others concerned with my care

to abide by my wishes and respect my legal right to refuse medical care.

OPTIONAL Instructions that may help your doctor know exactly what your wishes are: I also make the following instructions on specific treatments that I

do or do not want, and/or conditions that are important to me. (Use additional paper if necessary; sign, date and have witnesses sign the additional sheets.)

Additional Instructions:

OPTIONAL: I want the following person to act on my behalf to see that the provisions of this Living Will are carried out:

Name _______________________________ Address __________________________________________ Phone ________ __________________________

I am competent and I understand the importance of this Declaration, and sign it in the presence of my two witnesses.

Signature

Date _____________________________________

Witness

Print Name

Signature

Address

Phone ____________

Phone ___________