Fillable Living Will Directive (Page 9 of 10) in pdf

Form 2: Notary Public

LIVING WILL DIRECTIVE

My wishes regarding life-prolonging treatment and artificially provided nutrition and hydration to be provided to me if I no

longer have decisional capacity, have a terminal condition, or become permanently unconscious have been indicated by

checking and initialing the appropriate lines below. By checking and initialing the appropriate lines, I specifically:

.... Designate ............................................................... as my health care surrogate(s) to make health care decisions for

me in accordance with this directive when I no longer have decisional capacity. If ...............................................................

refuses or is not able to act for me, I designate ............................................................... as my health care surrogate(s).

Any prior designation is revoked.

If I do not designate a surrogate, the following are my directions to my attending physician. If I have designated a

surrogate, my surrogate shall comply with my wishes as indicated below:

.... Direct that treatment be withheld or withdrawn, and that I be permitted to die naturally with only the administration of

medication or the performance of any medical treatment deemed necessary to alleviate pain.

.... DO NOT authorize that life-prolonging treatment be withheld or withdrawn.

.... Authorize the withholding or withdrawal of artificially provided food, water, or other artificially provided nourishment or

fluids.

.... DO NOT authorize the withholding or withdrawal of artificially provided food, water, or other artificially provided

nourishment or fluids.

.... Authorize my surrogate, designated above, to withhold or withdraw artificially provided nourishment or fluids, or other

treatment if the surrogate determines that withholding or withdrawing is in my best interest; but I do not mandate that

withholding or withdrawing.

.... Authorize the giving of all or any part of my body upon death for any purpose specified in KRS 311.185.

.... DO NOT authorize the giving of all or any part of my body upon death.

In the absence of my ability to give directions regarding the use of life-prolonging treatment and artificially provided

nutrition and hydration, it is my intention that this directive shall be honored by my attending physician, my family, and any

surrogate designated pursuant to this directive as the final expression of my legal right to refuse medical or surgical

treatment and I accept the consequences of the refusal.

If I have been diagnosed as pregnant and that diagnosis is known to my attending physician, this directive shall have no

force or effect during the course of my pregnancy.

I understand the full import of this directive and I am emotionally and mentally competent to make this directive.

Signed this .... day of .........., 20___.

Grantor:

___________________________

Address:

___________________________

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Living Will Directive Page 9