Living Will Form
Living Will Form
Declaration
I,
Life-Sustaining Treatment
If at any time I am diagnosed with an incurable or irreversible medical condition that, without life-sustaining treatment, will result in my death within a relatively short period of time, I direct the following:
-
I wish to receive life-sustaining treatment.
-
I do not wish to receive life-sustaining treatment.
Artificial Nutrition and Hydration
If I am in a state where I am unable to eat or drink on my own, I direct the following regarding artificial nutrition and hydration:
-
I wish to receive artificial nutrition and hydration.
-
I do not wish to receive artificial nutrition and hydration.
Pain Relief
Regardless of my choices regarding life-sustaining treatment or artificial nutrition and hydration:
-
I wish to receive pain relief treatment.
-
I do not wish to receive pain relief treatment.
Health Care Proxy
In the event that I am unable to make health care decisions for myself, I designate the following person as my health care proxy:
Name
Phone number
Address
If the person named above is unable or unwilling to act as my health care proxy, I designate the following alternate:
Name
Phone number
Address
Signatures
I understand that this Living Will expresses my legal right to refuse or accept treatment under the law.
Declarant
Name:
Date:
|
Witness 1
Name: Date: |
Witness 2
Name: Date: |
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