Tennessee Living Will
This Living Will is made in accordance with the Tennessee Right to Natural Death Act, determining the course of medical treatment in the event that I can no longer express my wishes myself.
Part 1: Declaration
I, ______________________ (full legal name), born on ______________________ (date of birth), residing at ______________________ (full address, city, state, zip code), being of sound mind, do hereby declare:
It is my wish that if the time comes when I can no longer make health care decisions for myself due to incapacity, the instructions in this Living Will should guide those who are entrusted with my care and treatment.
Part 2: Health Care Directives
In the event that I suffer a terminal condition, or an irreversible condition that will result in my death without the administration of life-sustaining treatment, the following are my instructions:
- Life-sustaining treatment __________ (initial one): SHOULD be administered; SHOULD NOT be administered.
- Artificial nutrition and hydration __________ (initial one): SHOULD be provided; SHOULD NOT be provided, even if the withholding of it results in my death.
- Pain relieving treatment: I wish to receive medication or other interventions to alleviate pain, even if it hastens my death, to the extent permitted by law.
Part 3: Appointment of Health Care Agent
I hereby designate ______________________ (full legal name of agent), residing at ______________________ (full address, city, state, zip code), as my Health Care Agent to make medical treatment decisions on my behalf, should I become incapable of making my own decisions.
In the event that the above-named agent is unable or unwilling to act on my behalf, I hereby designate ______________________ (full legal name of alternate agent), residing at ______________________ (full address, city, state, zip code), as my alternate Health Care Agent.
Part 4: Signature
By my signature below, I affirm that I am of legal age to make this Living Will, am not under any undue influence, and fully understand its contents.
Signature: ______________________ (sign here)
Date: ______________________ (date)
Witness 1 Signature: ______________________ (sign here)
Witness 1 Printed Name: ______________________
Witness 1 Date: ______________________ (date)
Witness 2 Signature: ______________________ (sign here)
Witness 2 Printed Name: ______________________
Witness 2 Date: ______________________ (date)
Part 5: Notarization
This document was acknowledged before me on ________________ (date) by ______________________ (name of declarant).
Notary Public: ______________________ (signature)
My commission expires: ______________________.