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If you would like to complete a living will using this form, print and complete the form and be sure that it is signed as indicated.
This advance directive is one of many forms of advance directives that are available; other forms are equally valid. Completion of an advanced directive is voluntary. You medical care is not contingent upon your completion of an advance directive. Please consider carefully whatever advance directive you may choose. It is important that each person completing an advance directive be fully informed about its meanings and implications.
ADVANCE DIRECTIVE FOR HEALTH CARE (LIVING WILL)
A. I, ____________________________________________________, being of sound mind, hereby declare and make known my instructions and wishes for future health care in the event that, for reasons due to physical or mental incapacity, I am unable to participate in decisions regarding my care.
B. Please initial the statement or statements with which you agree. (Select #1 or #2, but not both.)
_______ 1. I direct that all medically appropriate measures be provided to sustain my life, regardless of my physical or mental condition.
_______ 2. If I experience extreme mental or physical deterioration such that there is no reasonable expectation of recovery or regaining a meaningful quality of life, then life-prolonging measures should not be initiated; or if they have been, they should be discontinued. Those life-sustaining procedures or treatments that may be withheld or withdrawn include but are not limited to cardiac resuscitation, respiratory support (ventilator) and artificially administered fluids and nutrition and dialysis.
_______ 3. I direct that I be given appropriate medical care to alleviate pain and keep me comfortable.
C. Additional comments or instructions:
______________________________________________________________________
______________________________________________________________________
D. After death, it may be possible to transplant human organs or tissues in order to save or improve the lives of others.
| I wish to be an organ donor: |
___Yes ___No |
| I wish to be a tissue donor: |
___Yes ___No |
Comments:
______________________________________________________________________
______________________________________________________________________
Designation of a health care representative. I hereby designate:
______________________________________________________________________
Name
Relationship
Telephone
______________________________________________________________________
Street
City
State
Zip
as my health care representative to make decisions about accepting, refusing or withdrawing treatment in accordance to my wishes as stated in this document. In the event, my wishes are not clear, or a situation arises that I did not anticipate, my health care representative is authorized to make decisions in my best interests based upon what is known of my wishes.
F. Alternative representative: If the person I have designated above is unable to act as my health care representative, I hereby designate the following person(s) to do so.
1._____________________________________________________________________
Name
Relationship Telephone
_______________________________________________________________________
Street
City
State
Zip
2._____________________________________________________________________
Name
Relationship
Telephone
_______________________________________________________________________
Street
City State
Zip
G. I have discussed my wishes with these persons and trust their judgment on my behalf. I understand the purpose and effect of this document and I sign it knowingly, voluntarily after careful deliberation.
______________________________________________________________________
Signature
Date
Witnesses (cannot be health care representative or alternative representative listed in E or F and must be at least 18 years of age.) I declare that the person who signed this document, did so in my presence, and that he or she appears to be of sound mind and free of undue influence.
_____________________________________________________________________
Witness
Date
Witness
Date
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