Kentucky Living Will
I. Introduction
This living will document is prepared by [Your Name], a resident of [Your Address], to express my wishes regarding medical treatment if I am unable to communicate my decisions due to incapacity.
II. Declaration of Intent
I, [Your Name], being of sound mind and body, hereby declare this to be my living will. This document reflects my desires concerning medical care and treatment if I am unable to participate in medical treatment decisions.
III. Health Care Agent
A. Appointment of Health Care Agent
I appoint [Your Health Care Agent], residing at [Health Care Agent Address] as my health care agent to make medical decisions on my behalf should I become incapacitated.
B. Successor Health Care Agent
If my primary agent is unable or unwilling to serve, I appoint [Successor Health Care Agent] residing at [Successor Health Care Agent Address] as my successor agent.
IV. Health Care Instructions
If I am unable to make or communicate my own healthcare decisions, I provide the following instructions:
A. End-of-Life Care
Prolonging Life: If I am in a terminal condition with no reasonable expectation of recovery, I do not wish to be kept alive through artificial means such as life support or CPR.
Comfort Care: I request palliative care and pain relief measures even if they might hasten my death.
B. Specific Treatments
Tube Feeding: I [do/do not] consent to tube feeding if I am unable to eat or drink.
Dialysis: I [do/do not] consent to dialysis if my kidneys fail.
Antibiotics: I [do/do not] consent to antibiotic treatment for infections.
C. Organ Donation
V. Additional Provisions
Revocation: I reserve the right to revoke or amend this living will at any time.
Acknowledgment: I affirm that I am signing this document voluntarily and understand its contents.
VI. Signature and Witnesses
I sign this Living Will on [Date] in the presence of the following witnesses who attest to my signing willingly and voluntarily.
[Your Name]
Witness 1
Name: [Witness 1 Name]
Address: [Witness 1 Address]
Witness 2
Name: [Witness 2 Name]
Address: [Witness 2 Address]
VII. Notary Acknowledgment
County of [County Name], State of Kentucky
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]
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