Fillable Printable Kentucky Living Will Packet
Fillable Printable Kentucky Living Will Packet
Kentucky Living Will Packet
LIVING WILL PACKET
KENTUCKY
e Office of the Attorney General
Jack Conway, Attorney General
Living WiLLs in KentucKy
A Living Will gives you a voice in decisions about your medical care when you are
unconscious or too ill to communicate. As long as you are able to express your own
decisions, your Living Will will not be used and you can accept or refuse any medical
treatment. But if you become seriously ill, you may lose the ability to participate in decisions
about your own treatment.
You have the right to make decisions about your health care. No
health care may be given to you over your objection, and necessary
health care may not be stopped or withheld if you object.
The Kentucky Living Will Directive Act of 1994 was passed to ensure that citizens have the
right to make decisions regarding their own medical care, including the right to accept or
refuse treatment. This right to decide — to say yes or no to proposed treatment — applies
to treatments that extend life, like a breathing machine or a feeding tube.
In Kentucky a Living Will allows you to leave instructions in four critical areas. You can:
Designate a Health Care Surrogate
Refuse or request life prolonging treatment
Refuse or request articial feeding or hydration (tube feeding)
Express your wishes regarding organ donation
Everyone age 18 or older can have a Living Will. The effectiveness of a Living Will is
suspended during pregnancy.
It is not necessary that you have an attorney draw up your Living Will. Kentucky law
(KRS 311.625) actually species the form you should ll out. You probably should see an
attorney if you make changes to the Living Will form. The law also prohibits relatives, heirs,
health care providers or guardians from witnessing the Will. You may wish to use a Notary
Public in lieu of witnesses.
The Living Will form includes two sections. The rst section is the Health Care Surrogate
section which allows you to designate one or more persons, such as a family member
or close friend, to make health care decisions for you if you lose the ability to decide for
yourself. The second section is the Living Will section in which you may make your wishes
known regarding life-prolonging treatment so your Health Care Surrogate or Doctor will
know what you want them to do. You can also decide whether to donate any of your organs
in the event of your death.
When choosing a surrogate, remember that the person you name will have the power
to make important treatment decisions, even if other people close to you might urge a
different decision. Choose the person best qualied to be your health care surrogate. Also,
consider picking a back-up person, in case your rst choice isn’t available when needed.
Be sure to tell the person that you have named them a surrogate and make sure that
the person understands what’s most important to you. Your wishes should be laid out
specically in the Living Will.
If you decide to make a Living Will, be sure to talk about it with your family and your doctor.
The conversation is just as important as the document.
A copy of any Living Will should be put in your medical records. Each time you are admitted
for an overnight stay in a hospital or nursing home, you will be asked whether you have a
Living Will. You are responsible for telling your hospital or nursing home that you have a
Living Will.
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If there is anything you do not understand regarding the form, you might want to discuss
it with an attorney. You can also ask your doctor to explain the medical issues. When
completing the form, you may complete all of the form, or only the parts you want to use.
You are not required by law to use these forms. Different forms, written the way you want,
may also be used. You should consult with an attorney for advice on drafting your own
forms.
You are not required to make a Living Will to receive healthcare or for any other reason. The
decision to make a Living Will must be your own personal decision and should only be made
after serious consideration.
For additional copies of this packet, you may download it from the Attorney General’s
website at ag.ky.gov/livingwill or make photocopies of this packet.
This packet is provided to you by the Ofce of the Attorney General for informational purposes only.
The OAG does not discriminate on the basis of race, color, national origin, sex, religion, age or disability in employment
or in the provision of services and provides upon request, reasonable accommodation necessary to afford individuals
with disabilities an equal opportunity to participate in all programs and activities.
Copies printed with state funds.
instructions for compLeting the KentucKy Living
WiLL form
The Living Will form should be used to let your physician and your family know what kind of
life-sustaining treatments you want to receive if you become terminally ill or permanently
unconscious and are unable to make your own decisions. This form should also be used if
you would like to designate someone to make those healthcare decisions for you should you
become unable to express your wishes.
NOTE: You may ll out all or part of the form according to your
wishes. Keep in mind that lling out this form is not required for any
type of healthcare or any other reason. Filling out this form should
solely be a personal decision.
Read over all information carefully before lling out any part of the form.
At the top of the form in the designated area, print your full name and birth date.
The rst section of the form on page one relates to designating a “Health Care
Surrogate.” Fill this section out if you would like to choose someone to make your
healthcare decisions for you should you become unable to do so yourself. When choosing
a surrogate, remember that the person you name will have the power to make important
treatment decisions. Choose the person best qualied to be your health care surrogate.
Also, consider picking a back-up person, in case your rst choice isn’t available when
needed. Be sure to tell the person that you have named them a surrogate and make
sure that the person understands what’s most important to you. Do not complete this
section if you do not wish to name a surrogate.
The next section of the form is the “Living Will Directive.” Fill out this section to identify
what kinds of life-sustaining treatments you want to receive should you become
terminally ill or permanently unconscious.
Life Prolonging Treatment
Under this bolded section on page one, you may designate whether or not you
wish to receive treatment (such as a life support machine), and be permitted
to die naturally, with only the administration of medication or treatment
deemed necessary to alleviate pain. If you do not want treatment, except
for pain, and would like to die naturally, check and initial the rst line. If you
want life-sustaining treatment, check and initial the second line. Check and
initial only one line.
Nourishment and/or Fluids
Under this bolded section on page two, you may designate whether or not you
wish to receive articially provided food, water, or other articially provided
nourishment or uids (such as a feeding tube). If you do not want to receive
articial nourishment or uids, check and initial the rst line. If you want to
receive nourishment and/or uids, check and initial the second line. Check
and initial only one line.
Surrogate Determination of Best Interest
Important: This section cannot be completed if you have completed
the two previous bolded sections. Under this bolded section on page two,
IF you have designated a person as your surrogate in the rst section, you
may allow that person to make decisions for you regarding life-sustaining
treatments and/or nourishment. Check and initial this line ONLY if you wish
to allow your surrogate to make decisions for you and if you do not want to
detail your specic life-sustaining wishes on this form.
Organ/Tissue Donation
Under this bolded section on page two, you may designate whether or not
to donate your all or any part of your body upon your death. If you wish to
donate all or part of your body, check and initial the rst line. If you do not
want to donate all or part of your body, check and initial the second line.
Check and initial only one line.
1.
2.
3.
4.
On page three, you will sign and date the form. Sign and date the form in the
presence of two witnesses over the age of 18 OR in the presence of a Notary
Public.
The following people CANNOT be a witness to or serve as a notary public:
A blood relative of yours;
A person who is going to inherit your property under Kentucky law;
An employee of a health care facility in which you are a patient (unless the
employee serves as a notary public);
Your attending physician; or
Any person directly nancially responsible for your health care.
Once you have lled out the Living Will and either signed it in the presence of witnesses
or in the presence of a notary public, give a copy to your personal physician and any
contacts you have listed in the Living Will. A copy of any Living Will should be put in
your medical records. Remember, you are responsible for telling your hospital or nursing
home that you have a Living Will. Do not send your Living Will to the Ofce of the
Attorney General.
5.
a)
b)
c)
d)
e)
6.
KentucKy Living WiLL Directive anD heaLth care
surrogate Designation of
_________________________________________
(PRINTED NAME)
___________________________
(DATE OF BIRTH)
My wishes regarding life-prolonging treatment and articially provided nutrition and
hydration to be provided to me if I no longer have decisional capacity, have a terminal
condition, or become permanently unconscious have been indicated by checking and
initialing the appropriate lines below.
heaLth care surrogate Designation
By checking and initialing the line below, I specically:
_______ (check box and initial line, if you desire to name a surrogate)
Designate ___________________________ as my health care surrogate(s) to
make health care decisions for me in accordance with this directive when I no
longer have decisional capacity. If _______________________ refuses or is not
able to act for me, I designate __________________________ as my health
care surrogate(s).
Any prior designation is revoked.
Living WiLL Directive
If I do not designate a surrogate, the following are my directions to my attending physician.
If I have designated a surrogate, my surrogate shall comply with my wishes as indicated
below. By checking and initialing the lines below, I specically:
Life Prolonging Treatment (check and initial only one)
_______ (check box and initial line, if you desire the option below)
Direct that treatment be withheld or withdrawn, and that I be permitted to die
naturally with only the administration of medication or the performance of any
medical treatment deemed necessary to alleviate pain.
_______ (check box and initial line, if you desire the option below)
DO NOT authorize that life-prolonging treatment be withheld or withdrawn.
Nourishment and/or Fluids (check and initial only one)
_______ (check box and initial line, if you desire the option below)
Authorize the withholding or withdrawal of articially provided food, water, or
other articially provided nourishment or uids.
Living WiLL Directive — continueD
_______ (check box and initial line, if you desire the option below)
DO NOT authorize the withholding or withdrawal of articially provided food,
water, or other articially provided nourishment or uids.
Surrogate Determination of Best Interest
NOTE: If you desire this option, DO NOT choose any of the preceding options
regarding Life Prolonging Treatment and Nourishment and/or Fluids
_______ (check box and initial line, if you desire the option below)
Authorize my surrogate, as designated on the previous page, to withhold or
withdraw articially provided nourishment or uids, or other treatment if the
surrogate determines that withholding or withdrawing is in my best interest; but I
do not mandate that withholding or withdrawing.
Organ/Tissue/Eye Donation
I certify that I am eighteen (18) years of age or older and of sound mind, and that upon my
death, I hereby give:
Check appropriate boxes and initial the line beside that box:
_______ Any needed organs, tissues, and eye/corneas
or
The following organs or tissues only (check and initial all that apply):
_______ All needed organs
_______ All needed tissues
_______ Corneas
_______ Eyes
_______ Other
or
_______ Only the specied organs/tissues as listed:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Organs that can be donated: heart, lungs, liver, pancreas, kidneys, and small bowel.
Tissues that can currently be donated: skin (outermost layer from lower trunk and
abdomen), bone, heart valves, leg veins, pericardium, vertebral bodies.
Eye donation can be the corneas (outer most layer), the sclera (shell), or the entire eye.
In the absence of my ability to give directions regarding the use of life-prolonging treatment
and articially provided nutrition and hydration, it is my intention that this directive shall be
honored by my attending physician, my family, and any surrogate designated pursuant to
this directive as the nal expression of my legal right to refuse medical or surgical treatment
and I accept the consequences of the refusal.
If I have been diagnosed as pregnant and that diagnosis is known to my attending
physician, this directive shall have no force or effect during the course of my pregnancy.
I understand the full import of this directive and I am emotionally and mentally competent
to make this directive.
Signed this ______ day of ____________, 20____
_________________________________________________________________________
(signature and address of the grantor)
Have two adults witness your signature OR have signature notarized.*
In our joint presence, the grantor, who is of sound mind and eighteen (18) years of age, or
older, voluntarily dated and signed this writing or directed it to be dated and signed for the
grantor.
_________________________________________________________________________
(signature and address of witness)
_________________________________________________________________________
(signature and address of witness)
or
COMMONWEALTH OF KENTUCKY, ______________ County
Before me, the undersigned authority, came the grantor who is of sound mind and eighteen
(18) years of age or older, and acknowledged that he/she voluntarily dated and signed this
writing or directed it to be signed and dated as above.
Done this ________ day of ___________, 20_____
_________________________________________ ____________________
Signature of Notary Public Date commission expires
* None of the following shall be a witness to or serve as a notary public or other person authorized to administer oaths
in regard to any advance directive made under this section:
A blood relative of the grantor;
A beneciary of the grantor under descent and distribution statutes of the Commonwealth;
An employee of a health care facility in which the grantor is a patient, unless the employee serves as a
notary public;
An attending physician of the grantor; or
Any person directly nancially responsible for the grantor’s health care.
NOTICE: Execution of this document restricts withholding and withdrawing of some medical procedures. Consult
Kentucky Revised Statutes or your attorney.
A person designated as a surrogate pursuant to an advance directive may resign at any time by giving written notice
to the grantor; to the immediate successor surrogate, if any; to the attending physician; and to any health care
facility which is then waiting for the surrogate to make a health care decision.
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b)
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