Living Will
This Living Will is executed in accordance with the laws of [State Name]. It expresses my wishes regarding medical treatment in the event that I am unable to communicate my wishes myself.
Declaration
I, [Your Full Name], born on [Date of Birth], residing at [Your Address], declare that this document reflects my wishes about medical treatment under the conditions specified below.
Conditions Under Which This Will Applies
- If I am diagnosed with a terminal condition and death is expected within a short time.
- If I am in a persistent vegetative state or have an irreversible condition that prevents me from communicating my wishes.
Wishes Regarding Medical Treatment
In the event that I am unable to make decisions about my medical care, I express the following wishes:
- I do not wish to receive life-sustaining treatment if I am terminally ill.
- I wish to receive pain relief even if it may hasten my death.
- I do not want resuscitation attempts in the event of my heart stopping or cessation of breathing.
- If I enter a state of unconsciousness and my condition is deemed irreversible, I prefer to forgo artificial nutrition and hydration.
Appointment of Health Care Proxy
I designate [Proxy's Full Name], residing at [Proxy's Address], as my health care proxy. In the absence of the appointed person, I designate [Alternate Proxy's Full Name], residing at [Alternate Proxy's Address], as my alternate proxy.
Revocation of Previous Living Wills
This document revokes any prior Living Wills or similar directives I have executed.
Signatures
Signed on this [Day] day of [Month], [Year].
Signature: __________________________
print name: [Your Printed Name]
Witnesses
This Living Will must be signed in the presence of two witnesses who are not related to me, do not inherit from me, and are not involved in my medical care.
- Witness 1 Name: ______________________ Signature: ____________________ Date: ____________
- Witness 2 Name: ______________________ Signature: ____________________ Date: ____________