Indiana Living Will
Indiana Living Will
This document is a directive made by [YOUR NAME], to specify preferences regarding life-sustaining treatments. It is intended to guide healthcare providers and family members in honoring my wishes regarding medical interventions during critical situations where I am unable to communicate my preferences.
I. Declaration
I, [YOUR NAME], a resident of [YOUR ADDRESS, CITY, INDIANA, ZIP CODE], being of sound mind and not under duress, fraud, or undue influence, do hereby declare my intent and authorize the following concerning my health care treatment preferences.
II. Appointment of Health Care Representative
I designate [HEALTHCARE REPRESENTATIVE'S NAME] of [HEALTHCARE REPRESENTATIVE'S ADDRESS], as my primary Health Care Representative to make health care decisions if I am unable to do so. If the primary representative is unable or unwilling to serve, I designate [ALTERNATE REPRESENTATIVE'S NAME] of [ALTERNATE REPRESENTATIVE'S ADDRESS] as my alternate representative.
III. General Statement of Desires Concerning Life-Sustaining Procedures
I, in my capacity and authority, hereby provide explicit direction for particular life-sustaining treatments to be either administered or restrained. This is dependent upon the circumstances that arise and the medical situations that may present themselves.
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If I am in a terminal condition, life-sustaining treatments may be withheld or withdrawn if they only prolong the dying process.
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If I am in a state of permanent unconsciousness, I direct that life-sustaining procedures, including ventilators, tube feeding, and CPR, should not commence.
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In cases where recovery from a coma or vegetative state is unlikely, as certified by medical personnel, I request that all treatments that do not provide comfort or alleviate pain be withheld or discontinued.
IV. Additional Directives
The extra instructions or guidelines that I have put into place regarding my health care include:
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I do not wish to undergo surgical procedures, except when necessary to provide comfort or alleviate pain.
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I prefer to receive maximum pain relief, even if it may hasten death.
V. Signatures
I hereby assert that this declaration truthfully and precisely articulates my wishes regarding my healthcare treatment. By attaching my signature underneath, I provide confirmation and verification that I have made this directive known as a Living Will of my own volition, fully aware of the implications and willingly adhering to the decisions I've laid out.
[YOUR NAME]
[DATE SIGNED]
VI. Witnesses
This document must be signed in the presence of two competent adult witnesses, who must also sign the document in each other's presence. Witnesses should not be related to me by blood or marriage, entitled to any portion of my estate, or directly financially responsible for my medical care.
Witness 1:
[WITNESS 1'S NAME]
[DATE SIGNED]
Witness 2:
[WITNESS 2'S NAME]
[DATE SIGNED]
