Fillable Living Will Declaration (Page 2 of 3) in pdf

Living Will Declaration Page 2

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Complete Living Will Declaration with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

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(OR)

STATE OF_____________________________COUNTY OF__________________________

This instrument was acknowledged before me on___________________by__________________

(Seal, if any)

_____________________________________________________________

(Signature of Notary Public)

My appointment expires_________________________________________

This declaration and optional additional instructions may be revoked or changed by declarant at any time.

Optional Additional Instructions

I make these optional additional instructions to my living will to exercise my right to determine the course of

my health care and to provide clear and convincing proof of my treatment decisions when I lack the capacity to

make or communicate my decisions.

If there is a phrase, statement or section below with which you do not agree, draw a line through it with your

initials.

I direct all life-prolonging procedures be withheld or withdrawn when there is no hope of significant recovery,

and I have:

• a terminal condition; or

• a condition, disease or injury without hope of significant recovery and there is no reasonable expectation

that I will regain an acceptable quality of life; or

• substantial brain damage or brain disease which cannot be significantly reversed; or

• other_________________________________________________________________

I choose to have withheld or withdrawn the following life-prolonging procedures, when the above conditions

exist:

• surgery

• heart-lung resuscitation (CPR)

• antibiotics

• mechanical ventilator (respirator)

• dialysis

• tube feedings (food and water delivered through a tube in the vein, nose or stomach)

• other__________________________________________________________________

Living Will Declaration Page 2

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