California Living Will Template
This California Living Will is designed in accordance with the California Natural Death Act, allowing individuals to declare their wishes regarding the withholding or withdrawal of life-sustaining treatment. This document ensures that your healthcare preferences are respected and followed in the event that you are unable to communicate them yourself.
Part 1: Personal Information
Full Legal Name: __________________________________________________
Date of Birth (MM/DD/YYYY): _______________________________________
Address: _________________________________________________________
City: ___________________________ State: CA Zip Code: ______________
Primary Contact Number: ___________________________________________
Email Address: ___________________________________________________
Part 2: Declaration of Health Care Directive
I, ___________________________________ (full legal name), being of sound mind, hereby declare my desires regarding any medical treatment I may require if I become incapacitated or unable to communicate my healthcare wishes. This declaration is made pursuant to the California Natural Death Act.
Part 3: Life-Sustaining Treatment
In the event that I am in a terminal condition, persistent vegetative state, or irreversible coma, and am unable to express my healthcare choices, I direct that:
- My healthcare provider may withhold or withdraw life-sustaining treatment that serves only to prolong the process of dying.
- All treatments that might be considered to provide comfort care or alleviate pain are provided even if they do not prolong life.
- Specific treatments I do not want under any circumstances (e.g., ventilation, artificial nutrition, and hydration) are listed here: ___________________________________________.
Part 4: Designation of Health Care Agent
If I am unable to make my own healthcare decisions or communicate my healthcare wishes, I designate the following individual as my Health Care Agent:
Name: ___________________________________________________________
Relationship to me: _______________________________________________
Primary Contact Number: ___________________________________________
Alternate Contact Number: _________________________________________
This person will have the authority to make healthcare decisions on my behalf in accordance with what I have expressed in this document or, if not specified, in my best interests.
Part 5: Signature and Witnesses
This Living Will shall be in effect upon my signature and remains in effect until I revoke it in writing. A copy of this document shall have the same validity as the original.
Signature: _______________________________ Date: _________________
Witness:
I declare that the person who signed this document is personally known to me and appears to be of sound mind and under no duress, fraud, or undue influence.
1. Witness Name: _________________________________________________
Witness Signature: ________________________ Date: _________________
2. Witness Name: _________________________________________________
Witness Signature: ________________________ Date: _________________
Under California law, neither of the witnesses may be a healthcare provider of the declarant.