Fillable Printable Living Will Form Pdf

Living Will Form Pdf

STATE OF LOUISIANA

DECLARATION

Declaration made this day of

(month, year).

, being of sound

mind, willfully and voluntarily make known my desire that my dying shall not be artificially

prolonged under the circumstances set forth below and do hereby declare:

If at any time I should have an incurable injury, disease or illness, or be in a continual

profound comatose state with no reasonable chance of recovery, certified to be a terminal and

irreversible condition by two physicians who have personally examined me, one of whom shall

be my attending physician, and the physicians have determined that my death will occur whether

or not life-sustaining procedures are utilized and where the application of life-sustaining

procedure would serve only to prolong artificially the dying process, I direct (initial one only):

That

all life-sustaining procedures, including nutrition and hydration, be

withheld or withdrawn so that food and water will not be administered invasively.

That

life-sustaining procedures, except nutrition and hydration, be withheld or

withdrawn so that food and water can be administered invasively.

I further direct that I be permitted to die naturally with only the administration of

medication or the performance of any medical procedure deemed necessary to provide me with

comfort care.

In the absence of my ability to give directions regarding the use of such life-sustaining

procedures, it is my intention that this declaration shall be honored by my family and

physician(s) as the final expression of my legal right to refuse medical or surgical treatment and

accept the consequences from such refusal.

I understand the full import of this declaration and I am emotionally and mentally

competent to make this declaration.

Signed

City, Parish, and State of Residence

mind.

The declarant has been personally known to me and I believe him or her to be of sound

Witness

Rev. 02/2016

“LIVING WILL” DECLARATION

(R.S. 40:1151 et. sec.)

INSTRUCTIONS: Per R.S. 40:1151 et. sec., the Secretary of State’s Office has established a registry in which

a person, or his attorney, if authorized by the person to do so, may register the original, multiple original, or a

certified copy of the declaration. The filing fee is $20.00 to register the Declaration and receive a laminated

identification card and ID bracelet. The filing fee for a revocation is $5.00. If a certified copy is requested from

this office, there is an additional fee of $10.00. Mail the declaration, with the filing fee, to: Secretary of State,

Attn: Publications, P.O. Box 94125, Baton Rouge, LA 70804-9125