North Carolina Living Will
This Living Will is designed to express your wishes regarding medical treatment in the event that you become unable to communicate your desires due to illness or incapacity. This document complies with the laws of North Carolina, specifically under General Statutes § 90-321 through § 90-329.
Principal's Information:
Name: __________________________________
Date of Birth: ____________________________
Address: __________________________________
Designation of Healthcare Agent:
I appoint the following person as my healthcare agent to make medical decisions on my behalf if I am unable to do so:
Name: __________________________________
Address: __________________________________
Phone Number: ____________________________
General Statement of Intent:
In the event that I am diagnosed with a terminal condition or am in a state of permanent unconsciousness, I wish for the following:
- To receive only palliative care or pain relief.
- To withhold or withdraw life-prolonging measures.
- To allow natural death to occur.
Specific Wishes:
Please indicate your preferences regarding specific medical treatments:
- Resuscitation: Yes / No
- Mechanical Ventilation: Yes / No
- Dialysis: Yes / No
- Tube Feeding: Yes / No
Signatures:
By signing below, I affirm that I am of sound mind and that this Living Will reflects my wishes:
Signature: _______________________________ Date: ____________
Witness 1 Name: _________________________ Signature: _______________
Witness 2 Name: _________________________ Signature: _______________
This document must be witnessed by two adults who are not related to you or entitled to any part of your estate.
Make copies of this document and provide them to your healthcare agent, family members, and healthcare providers.