Living Will Template

I, [NAME], a resident of [CITY], [STATE], in [COUNTRY], with an address at [ADDRESS], being of sound mind, memory, disposition, understanding, and at least eighteen years of age, do willfully and freely, by this Living Will, direct my family, physician(s), attorney, and any other individuals who may in the future become responsible for my health and well-being and any decisions related thereto, whether partly or fully, to take the following actions in each of the circumstances described in this Living Will below.

  1. In the event that I develop a condition deemed to be “terminal” and my attending physician and one other physician have both determined/agreed that there is no chance for recovery from this terminal condition, I request/direct the following:

a. Indicate either “Do not prolong my life using artificial life support” or “Use whatever life-prolonging procedures are available to prolong my life.”

b. Indicate either “Do not administer food or water artificially” or “Administer food and water artificially” or “Administer food and water artificially only to the extent necessary to provide comfort or alleviate pain, provided such administration does not have the added effect of prolonging my life artificially.”

c. Indicate either “Administer necessary care in order to provide comfort and alleviate pain” or “Do not administer any care intended to provide comfort or alleviate pain” or “Administer necessary care in order to provide comfort and alleviate pain to the extent that such care does not also have the effect of prolonging my life artificially.”

  1. In the event that I fall into a coma and my attending physician and one other physician have both determined/agreed that there is no chance for recovery from this condition, I request/direct the following:

a. Indicate either “Do not prolong my life using artificial life support” or “Use whatever life-prolonging procedures are available to prolong my life.”

b. Indicate either “Do not administer food or water artificially” or “Administer food and water artificially” or “Administer food and water artificially only to the extent necessary to provide comfort or alleviate pain, provided such administration does not have the added effect of prolonging my life artificially.”

c. Indicate either “Administer necessary care in order to provide comfort and alleviate pain” or “Do not administer any care intended to provide comfort or alleviate pain” or “Administer necessary care in order to provide comfort and alleviate pain to the extent that such care does not also have the effect of prolonging my life artificially.”

  1. In the event that I am in a persistent vegetative state and my attending physician and one other physician have both determined/agreed that there is no chance for recovery from this condition, I request/direct the following:

a. Indicate either “Do not prolong my life using artificial life support” or “Use whatever life-prolonging procedures are available to prolong my life.”

b. Indicate either “Do not administer food or water artificially” or “Administer food and water artificially” or “Administer food and water artificially only to the extent necessary to provide comfort or alleviate pain, provided such administration does not have the added effect of prolonging my life artificially.”

c. Indicate either “Administer necessary care in order to provide comfort and alleviate pain” or “Do not administer any care intended to provide comfort or alleviate pain” or “Administer necessary care in order to provide comfort and alleviate pain to the extent that such care does not also have the effect of prolonging my life artificially.”

By my signature below, in front of the witnesses identified below, I hereby execute and subscribe to the declarations made in this Living Will both freely and voluntarily, and wholeheartedly request that my family, physician(s), attorney, and any other individuals who may in the future become responsible for my health and well-being and any decisions related thereto, whether partly or fully, all abide by my wishes as stated herein.

_________________________________    ______________

[NAME]                                                              DATE

PandaTip: The person providing the living will will need at least two witnesses and will need to ensure they are present at the time of signing the living will.  The laws regarding living wills vary in each State, so check the laws in your State for any additional requirements. For instance, some states may require a notary public to witness and sign.

This Living Will was signed by [NAME] in the presence of the following individuals, who by their signatures below, confirm that [NAME] was, at the time this document was signed, at least eighteen years of age, of sound mind, memory, disposition, understanding, and able to understand the weight of this health care decision, and not under any improper influence. The undersigned witnesses have subscribed this document in [NAME]’s presence and in each other’s presence at [NAME]’s request.

[WITNESS NAME]

[ADDRESS]

_________________________________    ______________

DATE

 

[WITNESS NAME]

[ADDRESS]

_________________________________    ______________

DATE

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