Living Will Declaration Form printable pdf download

Living Will Declaration Form

Nebraska State Unit on Aging

Surrogate Decision Making in Nebraska

Instructions

Living Will Declaration

How to Use This Form

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Read this guide carefully.

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Read the instructions on this page.

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Neatly print or type all information except where a signature is required.

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The blank spaces are available for you to personalize your living will.

For example, you may wish to limit the definition of life-sustaining treatment which generally

includes:

§ mechanical respirators which aid or replace normal breathing

§ cardiopulmonary resuscitation (CPR)

§ kidney dialysis

§ artificial nutrition and hydration (food and water) provided through feeding tubes

•

major surgery

If you wish to have artificial nutrition and hydration withheld or withdrawn, you must indicate it in

this paragraph.

If there are limitations or guidelines you want followed you may describe your wishes as follows:

“The term life-sustaining treatment shall include artificial nutrition and hydration.”

“The term life-sustaining treatment shall not include artificial nutrition and hydration.”

For more sample wording you can use, see the Appendix.

IF YOU DO NOT UNDERSTAND OR HAVE QUESTIONS ABOUT THE USE OF THIS

FORM, CONTACT A LAWYER, HEALTH-CARE PROVIDER, OR SOCIAL WORKER.

Living Will Declaration Form