Missouri Living Will
Missouri Living Will
I. Declaration
I, [Your Name], residing at [Your Address], being of sound mind and memory, do hereby declare this to be my Living Will. This document is made by Missouri laws and shall express my wishes concerning my medical treatment and care. Hereby, I appoint [Health Care Proxy's Name], as my health care proxy to make decisions on my behalf should I become unable to do so myself.
II. General Powers of Health Care Proxy
The person designated as my health care proxy shall have the power to make all health care decisions on my behalf that I could make myself, unless I specific limits to this power in this document including:
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Making decisions on the use of life-sustaining treatments,
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Consent or refusal of medical tests, medication, or surgical procedures,
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Full access to my medical records.
III. Life-Sustaining Treatment
Under the condition that I am diagnosed by two physicians who agree that my condition is terminal or I am permanently unconscious with no reasonable chance of recovery, I direct that:
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Life-sustaining treatments that serve only to prolong the process of dying or fail to provide comfort or alleviate pain shall not be provided or continued.
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Nutritional and hydration support be withdrawn or withheld unless my signing physician believes that it would provide comfort.
IV. Specific Wishes
If there are any specific treatments I wish to receive or refuse under certain conditions, I list them as follows:
[Do/Do not] wish to receive life-sustaining treatments including:
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Cardiopulmonary resuscitation (CPR)
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Mechanical ventilation
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Tube feeding (artificial nutrition/hydration)
V. Revocation and Execution
I reserve the right to revoke this declaration at any time. This Living Will shall be in effect until I have revoked it in writing. A photocopy of this document is to be considered as valid as the original.
VI. Signatures and Witnesses
I sign this Living Will in the presence of the following witnesses, who sign this Will at my request, in my presence, and the presence of each other.
Testator
[Your Name]
[Date]
Witness 1
Name: [Witness 1's Name]
Address: [Witness 1's Address]
Witness 2
Name: [Witness 2's Name]
Address: [Witness 2's Address]
VII. Notary Acknowledgment
County of [County Name], State of Missouri
On this [Date], before me, [Notary's Name], a notary public in and for the said state, personally appeared [Your Name], known to me to be the person described in and who executed the foregoing instrument, and acknowledged that he/she executed the same as his/her free act and deed.
Witness my hand and official seal.
Notary Public: [NOTARY'S NAME]
My Commission Expires: [EXPIRATION DATE]
