Living Wills were developed in recent times to help make advance decisions regarding end of life medical care and assistance. The purpose of a Living Will form is to give your doctors and care givers your personal directions on how you want to be cared for in the case of certain end of life circumstances.
A Living Will goes into effect when there is no hope for your recovery from an illness or injury. With a Living Will, you can stipulate what you want the doctors to do if you are in a vegetative state.
A Living Will is a written legal document and each state has its own forms and requirements for handling a Living Will. You may also need to have your Living Will signed by a witness or a notary.
SAMPLE FREE LIVING WILL FORM
Use this Living Will form to make decisions now about your medical care if you are ever in a terminal condition, a persistent vegetative state or an irreversible coma. You should talk to your doctor about what these terms mean. The Living Will states what choices you would have made for yourself if you were able to communicate.
It is your written directions to your health care representative if you have one, your family, your physician, and any other person who might be in a position to make medical care decisions for you. Talk to your family members, friends, and others you trust about your choices. Also, it is a good idea to talk with professionals such as your doctor, clergy and a lawyer before you complete and sign this Living Will.
If you decide this is the Living Will form you want to use, complete the form. Do not sign the Living Will form until your witness or a Notary Public is present to watch you sign it.
If you have a Living Will and a Durable Health Care Power of Attorney, you must attach the Living Will
to the Durable Health Care Power of Attorney.
Information about me: I am called the Principal
My Name: __________________________________________ My Age: _________________________________
My Address:_________________________________________ My Date of Birth: ___________________________
___________________________________________________ My Telephone: ____________________________
My decisions about End of Life Care:
______ A. Comfort Care Only: If I have a terminal condition I do not want my life to be prolonged, and I do not want life sustaining treatment, beyond comfort care, that would serve only to artificially delay the moment of my death. (NOTE: “Comfort care” means treatment in an attempt to protect and enhance the quality of life without artificially prolonging life.)
______ B. Specific Limitations on Medical Treatments I Want: (NOTE: Initial or mark one or more choices, talk to your
doctor about your choices.) If I have a terminal condition, or am in an irreversible coma or a persistent vegetative state that my doctors reasonably believe to be irreversible or incurable, I do want the medical treatment necessary to provide care that
would keep me comfortable, but I do not want the following:
____Cardiopulmonary resuscitation, for example, the use of drugs, electric shock, and artificial breathing
____Artificially administered food and fluids
____To be taken to a hospital if it is at all avoidable
_______ C. Pregnancy: Regardless of any other directions I have given in this Living Will, if I am known to be pregnant I do
not want life-sustaining treatment withheld or withdrawn if it is possible that the embryo/fetus will develop to the point of live birth with the continued application of life-sustaining treatment.
_______ D. Treatment Until My Medical Condition is Reasonably Known: Regardless of the directions I have made in
this Living Will, I do want the use of all medical care necessary to treat my condition until my doctors reasonably conclude that my condition is terminal or is irreversible and incurable, or I am in a persistent vegetative state.
_______ E. Direction to Prolong My Life: I want my life to be prolonged to the greatest extent possible
Other Statements Or Wishes I Want Followed For End of Life Care:
You can attach additional provisions or limitations on medical care that have not been included in this free Living Will form.
Initial or put a check mark by box A or B below. Be sure to include the attachment if you check B.
_______ A. I have not attached additional special provisions or limitations about End of Life Care I want.
_______ B. I have attached additional special provisions or limitations about End of Life Care I want.
SIGNATURE OR VERIFICATION
A. I am signing this Living Will as follows:
My Signature: ___________________________________________________ Date: _____________________________
B. I am physically unable to sign this Living Will, so a witness is verifying my desires as follows:
Witness Verification: I believe that this Living Will accurately expresses the wishes communicated to me by the principal of
He/she intends to adopt this Living Will at this time. He/she is physically unable to sign or mark this document
at this time. I verify that he/she directly indicated to me that the Living Will expresses his/her wishes and that he/she intends to adopt the Living Will at this time.
Witness Name (printed): ________________________________________________________________________________
Signature: _______________________________________________________ Date: _____________________________
SIGNATURE OF WITNESS OR NOTARY PUBLIC
At least one adult witness OR a Notary Public must witness you signing this document and then sign it. The witness
or Notary Public CANNOT be anyone who is: (a) under the age of 18; (b) related to you by blood, adoption, or marriage; (c)
entitled to any part of your estate; (d) appointed as your representative; or (e) involved in providing your health care at the time this document is signed.
A. Witness: I certify that I witnessed the signing of this document by the Principal. The person who signed this Living Will appeared to be of sound mind and under no pressure to make specific choices or sign the document. I understand the requirements of being a witness. I confirm the following:
_____I am not currently designated to make medical decisions for this person.
_____I am not directly involved in administering health care to this person.
_____I am not entitled to any portion of this person’s estate upon his or her death under a will or by operation of law.
_____I am not related to this person by blood, marriage or adoption.
Witness Name (printed): ___________________________________________________________________________
Signature: __________________________________________________________ Date: ______________________
B. Notary Public:
COUNTY OF____________________________ STATE OF_____________________________
WITNESS MY HAND AND SEAL this _______ day of ____________________, 20____.
Notary Public: ________________________________________________ My commission expires: _____________________