Living Will
This Living Will is prepared in accordance with the laws of the state of [Your State]. This document outlines my wishes regarding medical treatment in the event that I am unable to communicate my preferences.
Personal Information:
- Full Name: ______________________________________________________
- Date of Birth: __________________________________________________
- Address: _______________________________________________________
- City: _________________________ State: _________ Zip Code: _____
- Phone Number: ________________________________________________
Statements of Wishes:
- If I am diagnosed with a terminal illness or a condition that renders me permanently unconscious, I do not wish to receive any life-sustaining treatments that would delay my dying process.
- I wish to receive palliative care to ensure my comfort and dignity during my final days.
- If I have a diagnosed condition with no hope for recovery, my desire is to forgo life-prolonging interventions.
Healthcare Proxy:
I designate the following individual as my Healthcare Proxy to make medical decisions on my behalf if I am incapacitated:
- Full Name of Proxy: _______________________________________________
- Relationship: ____________________________________________________
- Phone Number: _________________________________________________
- Address: ________________________________________________________
Signatures:
I hereby affirm that I am of sound mind and execute this Living Will voluntarily. This document reflects my wishes regarding medical care.
- Patient Signature: ________________________________________________
- Date: ____________________________________________________________
- Witness Signature: _______________________________________________
- Date: ____________________________________________________________
Notarization (optional):
This Living Will may also be notarized for further validation:
- Notary Public Signature: __________________________________________
- Date: ___________________________________________________________
- My commission expires: ___________________________________________
It is important to share this Living Will with family, friends, and your healthcare provider. Keep a copy for your records and ensure that your designated Healthcare Proxy is aware of your wishes.