Georgia Living Will
This Georgia Living Will is made by [YOUR NAME] ("the Declarant"), born on [YOUR BIRTHDATE], and residing at [YOUR COMPANY ADDRESS]. This Directive is executed as a declaration of my wishes regarding my medical treatment and end-of-life care. I am of sound mind and voluntarily make this Directive.
I. Appointment of Health Care Agent
I hereby appoint the following individual as my Health Care Agent to make health care decisions for me when I am unable to do so:
Name: | [AGENT'S NAME] |
Relationship: | [AGENT'S RELATIONSHIP] |
Address: | [AGENT'S ADDRESS] |
Phone Number: | [AGENT'S PHONE NUMBER] |
Alternate Phone Number: | [AGENT'S ALTERNATE PHONE NUMBER] |
If my primary Health Care Agent is unable, unwilling, or unavailable to act as my agent, I designate the following individual as my alternate Health Care Agent:
Name: | [ALTERNATE AGENT'S NAME] |
Relationship: | [ALTERNATE AGENT'S RELATIONSHIP] |
Address: | [ALTERNATE AGENT'S ADDRESS] |
Phone Number: | [ALTERNATE AGENT'S PHONE NUMBER] |
Alternate Phone Number: | [ALTERNATE AGENT'S ALTERNATE PHONE NUMBER] |
II. General Powers of Health Care Agent
The individual who is designated as my Health Care Agent is given the authority to:
Make all necessary arrangements for medical care and treatment from health care professionals and facilities.
Consent to, refuse, or withdraw any type of medical treatment, even if death ensues.
Have access to medical records and information necessary to make informed treatment decisions.
Authorize my admission to or discharge (even against medical advice) from any hospital, nursing home, or other medical care facility.
III. Living Will / Health Care Treatment Preferences
The desires I hold regarding the kind of medical treatment I wish to receive can be detailed as follows:
If I am in a terminal condition, I direct that life-sustaining treatments and procedures be withheld or withdrawn so that my death will occur naturally.
If I am in a state of permanent unconsciousness, I direct that my healthcare providers forgo life-sustaining treatments, except as necessary to provide pain relief or comfort care.
I expressly desire palliative care, regardless of my other general or specific desires regarding health care treatments.
IV. Powers of Attorney for Health Care
If it becomes necessary for decisions regarding my health care to be made within a legal jurisdiction, such as a court of law, I hereby express my desire and decision to appoint my designated Health Care Agent. I intend for this individual to officially serve as my attorney-in-fact. In this capacity, they will be authorized to act on my behalf, solely about all decisions relating to my health care, which have been previously detailed and outlined above.
V. Execution
I affirm that this Georgia Living Will for Health Care accurately reflects my wishes and I understand its contents fully. This Directive is executed in the state of Georgia on the date of [DATE OF EXECUTION].
[YOUR NAME]
[DATE SIGNED]
VI. Witness Attestation
I was present when this document was signed. During the time of signing, it appeared to me that the individual, who we are referring to as the Declarant, was in a sound state of mind. I observed no signs of duress, fraud, or undue influence affecting the Declarant's decision to sign the document.
Witness 1:
[WITNESS 1'S NAME]
[DATE SIGNED]
Witness 2:
[WITNESS 2'S NAME]
[DATE SIGNED]
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