Living Will for [State Name] Residents
This Living Will is created in accordance with the laws of [State Name]. It reflects my wishes regarding medical treatment in the event that I am unable to communicate my preferences.
Personal Information
Full Name: ___________________________________________
Date of Birth: ______________________________________
Address: _____________________________________________
City, State, Zip Code: ______________________________
Phone Number: ______________________________________
Medical Preferences
In the event that I am diagnosed with a terminal illness or a condition that leaves me in a persistent vegetative state, I express the following wishes regarding my medical treatment:
Life-Sustaining Treatments
Initial only one option:
- ___ I wish to receive life-sustaining treatments, including but not limited to resuscitation, mechanical ventilation, and artificial nutrition and hydration.
- ___ I do not wish to receive life-sustaining treatments if I am in a terminal condition.
- ___ I wish to receive only comfort care measures to relieve pain and suffering.
Additional Instructions
Please specify any additional wishes regarding treatment or care:
__________________________________________________________
Organ Donation
Initial only one option:
- ___ I wish to donate any needed organs or tissues.
- ___ I do not wish to donate any organs or tissues.
Designation of Health Care Proxy
I designate the following person to act as my Health Care Proxy. They are authorized to make health care decisions on my behalf if I am unable to do so:
Name: ___________________________________________
Address: ______________________________________
Phone Number: __________________________________
Signature
By signing below, I affirm that I am of sound mind and that I am making this Living Will voluntarily, without coercion:
Signature: ________________________________________
Date: ___________________________________________
Witnesses
This Living Will must be signed in the presence of two witnesses who are not related to me and have no financial interest in my estate:
- Name: ___________________________________________ Signature: ________________________
- Name: ___________________________________________ Signature: ________________________