This Living Will is designed to convey the wishes of the individual regarding healthcare decisions in the event they are unable to make these decisions for themselves. While this template is created to be broadly applicable, it is important for users to verify the alignment of this document with the laws of their specific state.
Living Will Declaration of [Your Full Name]
I, ___________________ [Your Full Name], a resident of ___________________ [Your Address, City, State, ZIP Code], being of sound mind, do hereby declare this document as my Living Will. This document outlines my wishes regarding medical treatment in circumstances where I am unable to communicate my decisions due to incapacity.
This Living Will is made in accordance with the healthcare decision laws of my state of residence and is intended to guide those responsible for my care in making decisions that align with my values and wishes as stated herein.
Appointment of Health Care Agent
In the event that I am unable to make my own healthcare decisions, I designate the following individual as my Health Care Agent:
Name: ___________________
Relationship: ___________________
Address: ___________________
Phone Number: ___________________
General Instructions for Health Care
My health care agent is authorized to make all decisions on my behalf concerning my health care, including decisions about withholding or withdrawing treatment, and other decisions which may be necessary to enforce my wishes as detailed below:
- I wish to receive the maximum level of life-sustaining treatment in any situation where recovery is expected to be complete.
- If my condition is terminal and not expected to improve, I prefer palliative care aimed at comfort rather than life-sustaining treatment.
- In the event of permanent unconsciousness with no reasonable expectation of regaining consciousness, I do not wish to receive life-sustaining treatment beyond comfort care.
- I wish to donate any organs or tissues, should they be needed, upon my death.
Additional Instructions
You may add any specific instructions, limitations, or expansions of your agent's authority to make health care decisions for you:
_____________________________________________________________________________
_____________________________________________________________________________
Declaration
I understand that this Living Will represents my wishes regarding my healthcare. I am of sound mind and under no duress or undue influence while making these declarations. I reserve the right to amend or revoke this document at any time.
Signature: ___________________
Date: ___________________
Witness Declaration
I, ___________________ [Witness Name], declare that the individual making this Living Will:
- Is personally known to me and has identified themselves through ___________________ [Form of ID].
- Has signed this Living Will in my presence on this date: ___________________ [Date].
- Appears to be of sound mind and not under duress, fraud, or undue influence.
Witness Signature: ___________________
Date: ___________________