Fillable Printable Living Will Template

Living Will Template

ADVANCEDIRECTIVETOPHYSICIANS

Directivemadethis20

dayofSeptember,2013

DurablePowerofAttorneyforHealthCare

Iunderstandthatmywishesasexpressedinmyadvancedirectivemaynotcoverallpossible

aspectsofmycareifIbecomeincapacitated.Consequently,thereisapossibilitythatsomeone

elsewillhavetoconsentorrefusecertainmedicalinterventionsonmybehalfifIamunabletodo

so.

Therefore,I,JohnS.Doe,asprincipal,designatetheperson(s)listedbelowasmy

attorneyinfactforallhealthcaredecisions.

FirstChoice:

Name:JaneB.Doe

Address:100MainStreet

City/State/ZipCode:NY,NY10000

TelephoneNumber:(555)5555555

Iftheabovepersonisunableorunwillingtoserve,Idesignate:

SecondChoice:

Name:WillisDoe

Address:700MainStreet

City/State/ZipCode:100000

TelephoneNumber:(555)5550000

WhenIstillpossessthefullcapacitytomakemyownhealthcaredecisions,Iwillfully,and

voluntarilymakeknownmydesirethatmylifeshouldbeartificiallyprolongedunderthe

circumstancesbelow,anddoherebydeclarethat:

(a) IfIshouldbediagnosed,inwriting,tobeinaterminalconditionbytheattending

physician,orinapermanentunconsciousconditionbytwophysicians,andwheretheapplication

oflifesustainingtreatmentwouldserveonlytoartificiallyprolongtheprocessofmydying,Idirect

thatsuchtreatmentbewithheldorwithdrawn,andthatIbepermittedtodienaturally.I

understandbyusingthisformthataterminalconditionmeansanincurableandirreversible

conditioncausedbyinjury,disease,orillnessthatwould,withinreasonablemedicaljudgment,

causedeathwithinareasonableperiodoftimeinaccordancewithacceptedmedicalstandards,

andwheretheapplicationoflifesustainingtreatmentwouldserveonlytoprolongtheprocessof

dying.Ifurtherunderstandinusingthisformthatapermanentunconsciousconditionmeansan

incurableandirreversibleconditioninwhichIammedicallyassessedwithinreasonablemedical

judgmentashavingnoreasonableprobabilityofrecoveryfromanirreversiblecomaorpersistent

vegetativestate.

(b) Intheabsenceofmyabilitytogivedirectionsregardingtheuseofsuch

lifesustainingtreatment,itismyintentionthatthisdirectiveshallbehonoredbymyfamilyand

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

accepttheconsequencesofsuchrefusal.Ifanotherpersonisappointedtomakethese

decisionsforme,whetherthroughadurablepowerofattorneyorotherwise,Irequestthatthe

personbeguidedbythisdirectiveandanyotherclearexpressionsofmydesires.

condition:

Nutrition:

__ IDOwanttohaveartificiallyprovidednutrition.

JDx IDONOTwanttohaveartificiallyprovidednutrition.

Hydration:

__ IDOwanttohaveartificiallyprovidedhydration.

JDx IDONOTwanttohaveartificiallyprovidedhydration.

(d) Iunderstandthefullweightofthisdirective,andIamemotionallyandmentally

capabletomakethehealthcaredecisionscontainedherein.

(e) IunderstandthatbeforeIsignthisdirective,Icanaddtoordeletefromor

otherwisechangethewordingofthisdirectiveandthatImayaddtoordeletefromthisdirective

atanytimeandthatanychangesmustbeconsistentwithstatelaworfederalconstitutionallaw

tobelegallyvalid.

Signed: JohnDoe

Address: 100MainStreet,NY,NY10000

Eachofuspersonallyknowstheperson(the"declarer")signinghisnameabove,andwe

believethatpersontobeofsoundmind.Thesignatureabovewasmadeinthepresenceofboth

ofus.Neitherofusisrelatedtothedeclarerbybloodormarriagenoriseitherofus,toour

knowledge,entitledtoanyportionofthedeclarer'sestateuponthedeclarer'sdeathnordoes

eitherofushaveanyclaimagainstanyportionoftheestateatthistime.Neitherofusisthe

attendingphysician,anemployeeofthatphysician,oranemployeeofahealthcarefacilityin

whichthedeclarerisapatient.

Witness1

Witness2

Signature:

Mike Smith

Signature:

Bronwyn Tinnis

PrintedName:

MikeSmith

PrintedName:

BronwynTinnis