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Sample Living Will Form

Each of the fifty states have some law regarding the ability of patients to make decisions about their medical care before the need for treatment arises through the use of advance directives. The great majority of states allow for patients to draft living wills that set forth the type and duration of medical care that they wish to receive should they become unable to communicate those wishes on their own.

Although the law in each state will vary as to what can be included in a living will, the following sample can provide a general overview of what one may look like, and what information may be included. Of course, before assuming that this sample will be sufficient for your purposes, you should check the law in your jurisdiction or have an attorney review your advance directives. In some states, however, an unapproved document may have some persuasive effect.


LIVING WILL DECLARATION OF _______________

To my family, doctors, hospitals, surgeons, medical care providers, and all others concerned with my care:

I,______________________________, being of sound mind and rational thought, willfully and voluntarily make this declaration to be followed if I become incompetent or incapacitated to the extent that I am unable to communicate my wishes, desires and preferences on my own.

This declaration reflects my firm, informed, and settled commitment to refuse life-sustaining medical care and treatment under the circumstances that are indicated below.

This declaration and the following directions are an expression of my legal right to refuse medical care and treatment. I expect and trust the above-mentioned parties to regard themselves as legally and morally bound to act in accordance with my wishes, desires, and preferences. The above-mentioned parties should therefore be free from any legal liabilities for having followed this declaration and the directions that it contains.

DIRECTIONS

1.       I direct my attending physician or primary care physician to withhold or withdraw life-sustaining medical care and treatment that is serving only to prolong the process of my dying if I should be in an incurable or irreversible mental or physical condition with no reasonable medical expectation of recovery.

2.       I direct that treatment be limited to measures which are designed to keep me comfortable and to relieve pain, including any pain which might occur from the withholding or withdrawing of life-sustaining medical care or treatment.

3.       I direct that if I am in the condition described in item 1, above, it be remembered that I 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 the following 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 the condition 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 Will Declaration expresses my firm wishes, desires, and preferences and the fact that 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, which is an expression of both my common law and constitutional rights.

I make this Living Will Declaration the _______ day of __________, 20____.

_______________________________________________
Declarant's Signature

________________________________________________

________________________________________________

________________________________________________
Declarant's Address

WITNESS STATEMENTS

I declare that the person who signed or acknowledged this document is personally known to me, that he/she signed or acknowledged this Living Will Declaration in my presence, and that he/she appears to be of sound mind and under no duress, fraud, or undue influence.

________________________________________________
Witnesses' Signature

________________________________________________
Witnesses' Printed Name

________________________________________________

________________________________________________
Witnesses' Address

I declare that the person who signed or acknowledged this document is personally known to me, that he/she signed or acknowledged this Living Will Declaration in my presence, and that he/she appears to be of sound mind and under no duress, fraud, or undue influence.

________________________________________________
Witnesses' Signature

________________________________________________
Witnesses' Printed Name

________________________________________________

________________________________________________

________________________________________________
Witnesses' Address

NOTARIZATION

STATE OF _______________________, COUNTY OF ___________________

Subscribed and sworn to before me his ________ day of ________, 20_____.

_______________________________
Signature of Notary Public

My commission expires: ________________________________


NOTES ABOUT LIVING WILL DECLARATION FORM:

  • Paragraphs one and two can be tailored to suit your own desires. For example, you could redraft paragraph one to state that you would like to have life-sustaining treatments for "x" number of days or weeks and then if no progress is made and there is no reasonable hope of recovery, you would like to have the life-sustaining treatments withdrawn. As for paragraph two, if you do not wish to receive pain medications you can state those wishes there.


  • Paragraph three of the Declaration allows you to list all specific types of treatment you wish not to receive. If you do not have strong feelings about any particular types of treatment, you do not need to include this paragraph in your own living will. However, if you do have strong preferences, this is the place to list them.
    Examples: Antibiotics, artificial feedings, hydration and fluids, blood transfusions, cardiac resuscitation, dialysis, intravenous lines, invasive tests, respiratory therapy, mechanical respiratory assistance, and surgery.

    Note: For many people, taking away food and water from a dying person seems especially cruel because they may feel as though the person is starving or dehydrating to death. However, you have a right to make your specific wishes known on the subject. It is advisable, however, to be particularly clear on those issues so that there is no room for your loved ones to debate. In addition, they will likely feel less burdened by guilt if they are certain they are following your specific wishes not to be artificially fed or hydrated.

  • Paragraph four is the converse of paragraph three and allows you to clearly state what care and treatment you would like to receive. In addition, if you have specific instructions for other types of care, you may wish to include them in this paragraph.
    Examples: At-home or hospice care as the end approaches, feelings about religious practices or customs at a terminal stage (for instance, if you wish for a certain clergy member to be called and be present).
  • Paragraph six allows you to essentially "change" your wishes should you also have another medical condition when you become incapacitated or incompetent.
    Example: For women of child-bearing age, the desire to forego life-sustaining treatment may be compromised if they are pregnant. In those situations, they may wish to be kept alive, if possible, until the baby can be safely delivered at which point, if there has been no recovery or reasonable progress, they may wish to then have their life-sustaining treatments withdrawn.
Next Steps
Contact a qualified estate planning attorney to help you ensure
that your wishes are honored.
(e.g., Chicago, IL or 60611)

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