Living Will Form

Declaration

I, Name, being of sound mind, hereby declare this to be my Living Will. I make this declaration as a means to express my wishes regarding medical treatment if I am ever in a state where I am unable to make decisions for myself.

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:

If the person named above is unable or unwilling to act as my health care proxy, I designate the following alternate:

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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