Sample Living Will Form
Download article as a PDF| Also available in PDF | MS Word Each of the fifty states have some law regarding the abilityof patients to make decisions about their medical care before the need fortreatment arises through the use of advance directives. The great majority ofstates allow for patients to draft living wills that set forth the type andduration of medical care that they wish to receive should they become unable tocommunicate those wishes on their own. Although the law in each state will vary as to what can beincluded in a living will, the following sample can provide a general overviewof what one may look like, and what information may be included. Of course, before assuming that this sample will besufficient for your purposes, you should check the law in your jurisdiction orhave an attorney review your advance directives. In some states,however, an unapproved document may have some persuasive effect. LIVINGWILL DECLARATION OF _______________ To my family, doctors, hospitals, surgeons, medical careproviders, and all others concerned with my care: I,______________________________, being of sound mind and rationalthought, willfully and voluntarily make this declaration to befollowed if I become incompetent or incapacitated to the extentthat I am unable to communicate my wishes, desires and preferenceson my own. This declaration reflects my firm, informed, and settled commitmentto refuse life-sustaining medical care and treatment under thecircumstances that are indicated below. This declaration and the following directions are an expression ofmy legal right to refuse medical care and treatment. I expect andtrust the above-mentioned parties to regard themselves as legallyand morally bound to act in accordance with my wishes, desires, andpreferences. The above-mentioned parties should therefore be freefrom any legal liabilities for having followed this declaration andthe directions that it contains. DIRECTIONS 1. I direct myattending physician or primary care physician to withhold or withdrawlife-sustaining medical care and treatment that is serving only toprolong the process of my dying if I should be in an incurable orirreversible mental or physical condition with no reasonable medicalexpectation of recovery. |
2. I direct that treatment belimited to measures which are designed to keep me comfortableand to relieve pain, including any pain which might occur from thewithholding or withdrawing of life-sustaining medical care ortreatment. 3. I direct that if I am in the condition described in item 1, above, it be remembered thatI specifically do not want the following forms of medical care and treatment: A. _____________________________________ B. _____________________________________ C. _____________________________________ D. _____________________________________ E. _____________________________________ F. _____________________________________ G. _____________________________________ H. _____________________________________ I. _____________________________________ J. _____________________________________ K. _____________________________________ 4. I direct that if I am in the condition described in item 1, above, it be remembered that I specifically do want thefollowing forms of medical care and treatment: A. _____________________________________ B. _____________________________________ C. _____________________________________ D. _____________________________________ E. _____________________________________ F. _____________________________________ G. _____________________________________ H. _____________________________________ I. _____________________________________ J. _____________________________________ K. _____________________________________ |
| 5. I direct that if I am in thecondition described in item 1, above, and if I also have the condition or conditions of ____________________, that I receive the following medical care and treatment: This Living WillDeclaration expresses my firm wishes, desires, and preferences and the factthat I may have executed a form specified by the law of the State of _____________,may not be used a limiting or contradicting this Living Will Declaration, whichis an expression of both my common law and constitutional rights. I make this LivingWill Declaration the _______ day of __________, 20____. _______________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ WITNESSSTATEMENTS I declare that theperson who signed or acknowledged this document is personally known to me, thathe/she signed or acknowledged this Living Will Declaration in my presence, andthat he/she appears to be of sound mind and under no duress, fraud, or undueinfluence. ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ I declare that theperson who signed or acknowledged this document is personally known to me, thathe/she signed or acknowledged this Living Will Declaration in my presence, andthat he/she appears to be of sound mind and under no duress, fraud, or undue influence. ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ NOTARIZATION STATEOF _______________________, COUNTY OF ___________________ Subscribed andsworn to before me his ________ day of ________, 20_____. _______________________________ My commissionexpires: ________________________________ |
NOTES ABOUT LIVING WILL DECLARATION FORM:
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