Living Will Sample

The following sample of a living will is just what its name implies. It is nothing more than a possible sample that may be used. Individuals preparing a living will may include other directions or be more or less specific.

DECLARATION

I,              name of declarant            , being of sound mind, willfully and voluntarily make this declaration to be followed if I become incompetent.  This declaration reflects my firm and settled commitment to refuse life-sustaining treatment under the circumstances indicated below.

I direct my attending physician to withhold or withdraw life-sustaining treatment that serves only to prolong the process of my dying, if I should be in a terminal condition or in a state of permanent unconsciousness.

I direct that treatment be limited to measures to keep me comfortable and to relieve pain, including any pain that might occur by withholding or withdrawing life-sustaining treatment.

In addition, if I am in the condition described above, I feel especially strongly about the following forms of treatment:

I ( )do  ( )do not want cardiac resuscitation.

I ( )do  ( )do not want mechanical respiration.

I ( )do  ( )do not want tube feeding or any other artificial or invasive form of nutrition (food) or hydration (water).

I ( )do  ( )do not want blood or blood products.

I ( )do  ( )do not want any form of surgery or invasive diagnostic tests.

I ( )do  ( )do not want kidney dialysis.

I ( )do  ( )do not want antibiotics.

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I realize that if I do not specifically indicate my preference regarding any of the forms of treatment listed previously, I may receive that form of treatment.

Other instructions:                                                                                                                       

                                                                                                                                                  

                                                                                                                                                  

I ( )do  ( )do not want to designate another person as my surrogate to make medical treatment decisions for me if I should be incompetent and in a terminal condition or in a state of permanent unconsciousness.

Name and address of surrogate (if applicable):
                                                                                                                                                     

Name and address of substitute surrogate (if surrogate designated above is unable to serve):
                                                                                                                                                        

I made this declaration on the                                day of                                       (month, year).

Declarant's signature:                                                                                                                   

Declarant's address:                                                                                                                     

The declarant or the person on behalf of and at the direction of the declarant knowingly and voluntarily signed this writing by signature or mark in my presence.

 

Witness' signature:                                                                                                                       

Witness' address:                                                                                                                         

 

Witness' signature:                                                                                                                        

Witness' address: