SAMPLE LIVING WILL
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About This Form
The purpose of leaving a living will is to decide while you are competent your wishes regarding what life sustaining medical treatment should be withdrawn or withheld when you are incapable of giving informed consent as to medical treatments or procedures. You (the declarant} appoint a specific person (an agent) to make health care decisions for you when you are unable to make them for yourself. You do not give up the right to give directions to physicians and health care providers as long as you are able to do so. The document only becomes effective when you are unconscious or incompetent to give, withdraw or withhold informed consent as to your medical care and treatment.
Most states have specific statutory provisions outlining the form and content of a living will. By specifying what your wishes are in an advanced health care directive you provide guidance to those close to you at a difficult time.
LIVING WILL DECLARATION
To My Family, Physician and Medical Facility:
I, [YOUR NAME] , being of sound mind, voluntarily make known my desire that my dying not be artificially prolonged under the circumstances:
If I should have an injury, disease or illness regarded by my physician as incurable and terminal, and if my physician determines that the application of life-sustaining procedures would serve only to prolong artificially the dying process, I direct that such procedures be withheld or withdrawn and that I be permitted to die. I want treatment limited to those measures that will provide me with maximum comfort and freedom from pain. Should I become unable to participate in decisions with respect to my medical treatment, it is my intention that these directions be honored by my family and physicians as a final expression of my legal right to refuse medical treatment, and I accept the consequences of this refusal.
Date: ____________ Signed: ______________________________
[YOUR NAME]
_________________________ ________________________
Witness Witness
DESIGNATION CLAUSEShould I become comatose, incompetent or otherwise mentally or physically incapable of communication, I authorize [HEALTH CARE PROXY'S NAME] to make treatment decisions on my behalf in accordance with my Living Will Declaration. I have discussed my wishes concerning medical care with this person and I trust [HEALTH CARE PROXY'S NAME] 's judgment on my behalf.
Date: ____________ Signed: ______________________________
[YOUR NAME]
_________________________ ________________________
Witness Witness
ACKNOWLEDGEMENT
State of Ohio )
) ss.
County of [NOTARY COUNTY/PARISH/JUDICIAL DISTRICT]
)
On this _______ day of ________________________, _____,
before me, the undersigned Notary Public, personally appeared
[YOUR NAME] , known to me or satisfactorily proven to be the
person whose name is subscribed to the above Living Will
Declaration, and acknowledged that he executed the same for the
purpose expressed therein. Further, said person appeared to be of
sound mind and under no duress, fraud or undue influence.
______________________________Notary Public
My Commission Expires: ___________, _____
Copyright © 1997 OverDrive Systems, Inc.
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