Fillable Living Will Form La printable pdf download

State of Louisiana

Parish of ________

Declaration made _________ this day of ___________________

I, ___________________, being of sound mind, willfully and voluntarily hereby make

known my express wish and directive that my dying shall not be artificially prolonged

under the circumstances set forth below and do hereby declare that if, at any time, I

should have an incurable injury, disease, or illness and be certified by two (2) physicians

(one of whom shall be my attending physician) who have personally examined me and

determined that I am suffering from a terminal and irreversible condition, or to be in a

continual profound comatose state with no reasonable chance of recovery, and the said

physicians determine that the application of life-sustaining procedures would serve only

to prolong artificially the dying process, I direct that, except to the extent necessary to

give full effect to the provisions of any valid document executed by me providing for the

donation of any of my organ(s), such life-sustaining procedures be withheld or withdrawn

and that I be permitted to die naturally with only the administration of medication or the

performance of any medical procedures deemed necessary to provide me with comfort

care.

The life-sustaining procedures I choose to have withheld or withdrawn include but are

not limited to:

(check all that apply)

•

__heart-lung resuscitation (CPR)

•

__mechanical ventilator (respirator)

•

__tube feedings (food and water delivered through a tube)

•

__intravenous feedings (nutrition or fluids through an IV tube)

•

__surgery

•

__ other _________________

In the absence of my ability to give directions regarding the use of such life-

sustaining procedures, it is my intention that this declaration be honored by my

family and physician(s) as the final expression of my legal right to refuse medical

or surgical treatment and accept the consequences from such refusal.

I understand the full import of this declaration and I am emotionally and mentally

competent to make this declaration.

This declaration is made and signed by me in the presence of the undersigned

witnesses who are not related to me by blood or marriage and who do not stand to

inherit from me.

Signature of Declarant

____________________________________

The declarant is known to me and I believe the declarant to be of sound mind.

Living Will Form La