Living Will Template
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1
2LIVING WILL
OF
_____________________________________
I, __________________________________________________, a resident of the
City of ___________________, ________________ County, State of _____________,
being of sound and disposing mind, memory and understanding, do hereby willfully and
voluntarily make, publish and declare this to be my LIVING WILL, making known my
desire that my life shall not be artificially prolonged under the circumstances set forth
below, and do hereby declare:
1. This instrument is directed to my family, my physician(s), my attorney, my
clergyman, any medical facility in whose care I happen to be, and to any individual who
may become responsible for my health, welfare or affairs.
2. Death is as much a reality as birth, growth, maturity and old age. It is the one
certainty of life. Let this statement stand as an expression of my wishes now that I am
still of sound mind, for the time when I may no longer take part in decisions for my own
future.
3. If at any time I should have a terminal condition and my attending physician has
determined that there can be no recovery from such condition and my death is
imminent, where the application of life-prolonging procedures and "heroic measures"
would serve only to artificially prolong the dying process, I direct that such procedures
be withheld or withdrawn, and that I be permitted to die naturally. I do not fear death
itself as much as the indignities of deterioration, dependence and hopeless pain. I
therefore ask that medication be mercifully administered to me and that any medical
procedures be performed on me which are deemed necessary to provide me with
comfort, care or to alleviate pain.
4. In the absence of my ability to give directions regarding the use of such life-
prolonging procedures, it is my intention that this declaration shall be honored by my
family and physician as the final expression of my legal right to refuse medical or
surgical treatment and accept the consequences for such refusal.
5. In the event that I am diagnosed as comatose, incompetent, or otherwise mentally
or physically incapable of communication, I appoint ____________________________
to make binding decisions concerning my medical treatment.
6. If I have been diagnosed as pregnant and that diagnosis is known to my
physician, this declaration shall have no force or effect during the course of my
pregnancy.
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