Living Will
This Living Will is created in accordance with the applicable laws of the state of [STATE NAME].
Personal Information:
- Name: ____________________________
- Date of Birth: _____________________
- Address: __________________________
- City, State, Zip: _________________
- Phone Number: _____________________
Declaration:
I, [FULL NAME], being of sound mind, wish to make known my preferences regarding medical treatment in the event I become unable to communicate my wishes.
Medical Treatment Preferences:
- If I am diagnosed with a terminal condition, I do not want life-sustaining treatment that only prolongs the process of dying.
- If I am in a persistent vegetative state with no hope of recovery, I do not wish to receive life-sustaining treatment.
- I wish to receive comfort care, including pain management, regardless of my medical status.
Appointment of Healthcare Proxy:
I designate [HEALTHCARE PROXY NAME] as my Healthcare Proxy. They will make decisions on my behalf when I am unable to do so.
Proxy's Contact Information:
- Name: ____________________________
- Phone Number: _____________________
- Address: __________________________
Signatures:
By signing below, I acknowledge that I understand the contents of this Living Will and that I intend for it to be my final wishes concerning medical treatment.
______________________________________
Signature of Declarant
Date: ______________________________
Witness 1: ___________________________
Signature: ___________________________
Date: ______________________________
Witness 2: ___________________________
Signature: ___________________________
Date: ______________________________