Resources & Planning
LIVING WILL
(Advance Directive for Healthcare)
Declaration made this _____ day of _____________, 20_____
I. DECLARANT INFORMATION
I, (full legal name), being of sound mind, willfully and voluntarily make this Living Will to express my wishes regarding medical treatment in circumstances where I can no longer make decisions for myself.
Date of Birth:
Address:
City, State, ZIP:
Social Security Number (optional):
II. STATEMENT OF INTENT
This Living Will is intended to guide my family, healthcare providers, and any court of law regarding my wishes for medical treatment if I become unable to communicate my decisions due to:
- Terminal illness
- Permanent unconsciousness
- End-stage medical condition
- Other condition from which there is no reasonable expectation of recovery
III. END-OF-LIFE CARE PREFERENCES
If I am in a terminal condition or permanently unconscious state, as certified by two physicians, I direct the following:
A. Life-Sustaining Treatment
Select ONE option:
B. Artificial Nutrition and Hydration
Select ONE option:
C. Pain Management and Comfort Care
IV. SPECIFIC MEDICAL SITUATIONS
Cardiopulmonary Resuscitation (CPR)
Mechanical Ventilation
Organ and Tissue Donation
V. ADDITIONAL INSTRUCTIONS
Please include any other specific wishes regarding your medical care:
VI. HEALTHCARE AGENT (Optional)
I designate the following person as my healthcare agent to make medical decisions on my behalf if I cannot:
Primary Agent:
Name:
Relationship:
Phone:
Address:
Alternate Agent (if primary agent is unavailable):
Name:
Relationship:
Phone:
Address:
VII. DECLARATION AND SIGNATURE
I understand the full import of this declaration, and I am emotionally and mentally competent to make this Living Will. I understand that I may revoke this document at any time.
Signature of Declarant:
Date:
VIII. WITNESS STATEMENT
We declare that the person who signed this document, or asked another to sign this document on their behalf, did so in our presence, that they appeared to be of sound mind and not under duress or undue influence, and that we are not related to the declarant by blood or marriage, nor would we benefit from the declarant's estate.
Witness #1:
Signature:
Printed Name:
Address:
Date:
Witness #2:
Signature:
Printed Name:
Address:
Date:
IX. NOTARIZATION (if required in your state)
STATE OF
COUNTY OF
On this _____ day of _____________, 20_____, before me personally appeared , known to me to be the person described in and who executed the foregoing instrument, and acknowledged that they executed the same as their free act and deed.
Notary Public:
My Commission Expires:
[NOTARY SEAL]
IMPORTANT NOTES:
- State-Specific Requirements: Living will laws vary by state. Some states require specific language or forms. Check your state's requirements.
- Copies: Provide copies to your healthcare agent, primary care physician, family members, and keep a copy in an easily accessible location.
- Review Regularly: Review and update this document every few years or after major life changes.
- Revocation: You may revoke this Living Will at any time by destroying it or creating a new one.
- POLST/MOLST: Consider also completing a POLST (Physician Orders for Life-Sustaining Treatment) form with your doctor if you have serious illness.
- Legal Advice: This template is for informational purposes. Consult with an attorney to ensure compliance with your state's laws.