North Carolina Living Will
This Living Will is created in accordance with the laws of the State of North Carolina. It outlines my desires regarding medical treatment if I become incapacitated and unable to make my own healthcare decisions.
Principal Information:
- Full Name: _______________________________
- Date of Birth: _______________________________
- Address: _______________________________
Designation of Health Care Agent:
I, _______________________________, appoint the following individual as my Health Care Agent:
- Name: _______________________________
- Relationship: _______________________________
- Address: _______________________________
- Phone Number: _______________________________
If my Health Care Agent is unavailable, I designate the following individual as my alternate:
- Name: _______________________________
- Relationship: _______________________________
- Address: _______________________________
- Phone Number: _______________________________
Wishes Regarding Medical Treatment:
If I am unable to make my own decisions regarding medical care, I express my preferences as follows:
- Under no circumstances should life-prolonging measures be used if I have a terminal condition.
- If I am in a persistent vegetative state or have an irreversible condition that will not improve, I do not wish for artificial nutrition or hydration.
- In situations where I can only experience unbearable pain with no hope for recovery, I prefer comfort care that respects my dignity.
Signatures:
By signing below, I affirm that I understand the purpose of this Living Will and that it reflects my wishes regarding medical treatment.
- Signature of Principal: _______________________________ Date: _________________
- Signature of Witness 1: _______________________________ Date: _________________
- Signature of Witness 2: _______________________________ Date: _________________
Note: Witnesses must be at least 18 years old and cannot be related to you by blood or marriage. This document may be revoked at any time by notifying your Health Care Agent or any health care provider.