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Sample Living Will Form

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.

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LIVING WILL 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____.

_______________________________________________
Declarant's Signature

________________________________________________

________________________________________________

________________________________________________
Declarant's Address

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.

________________________________________________
Witnesses' Signature

________________________________________________
Witnesses' Printed Name

________________________________________________

________________________________________________
Witnesses' Address

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.

________________________________________________
Witnesses' Signature

________________________________________________
Witnesses' Printed Name

________________________________________________

________________________________________________

________________________________________________
Witnesses' Address

NOTARIZATION

STATEOF _______________________, COUNTY OF ___________________

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

_______________________________
Signature of Notary Public

My commissionexpires: ________________________________


NOTES ABOUT LIVING WILL DECLARATION FORM:

  • Paragraphs one and two can be tailored to suit yourown desires. For example, you could redraft paragraph one to state that youwould like to have life-sustaining treatments for "x" number of days or weeksand 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 forparagraph two, if you do not wish to receive pain medications you can statethose wishes there.


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

    Note: For manypeople, taking away food and water from a dying person seems especially cruelbecause 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. Itis advisable, however, to be particularly clear on those issues so that thereis no room for your loved ones to debate. In addition, they will likely feelless burdened by guilt if they are certain they are following your specificwishes not to be artificially fed or hydrated.

  • Paragraph four is the converse of paragraph three andallows you to clearly state what care and treatment you would like toreceive. In addition, if you have specific instructions for other types ofcare, you may wish to include them in this paragraph.
    Examples: At-home orhospice care as the end approaches, feelings about religious practices orcustoms at a terminal stage (for instance, if you wish for a certain clergymember to be called and be present).
  • Paragraph six allows you to essentially "change" yourwishes should you also have another medical condition when you becomeincapacitated or incompetent.
    Example: For womenof child-bearing age, the desire to forego life-sustaining treatment may becompromised if they are pregnant. In those situations, they may wish to be keptalive, if possible, until the baby can be safely delivered at which point, ifthere has been no recovery or reasonable progress, they may wish to then havetheir 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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