Comprehensive Living Will Template
This Living Will is designed to reflect my wishes regarding end-of-life care. It comes into effect only if I am unable to communicate my desires due to incapacity or medical condition. This document is created in accordance with the laws governing Advance Directives and Living Wills in the state in which it is executed and should be interpreted therein.
Personal Information
Full Name: _______________________________________________
Address: __________________________________________________
City, State, Zip Code: ______________________________________
Date of Birth: _____________________________________________
Social Security Number: ____________________________________
Healthcare Directives
It is my intention through this Living Will to provide clear and convincing evidence of my wishes concerning my health care. Should I be in a state where I am no longer able to make or communicate my own healthcare decisions due to incapacity, the directives below shall guide my care.
Life-Sustaining Treatment
In the event that I am in a terminal condition, permanently unconscious, or otherwise in a state considered as end-stage where the application of life-sustaining measures would only serve to artificially prolong my life, I direct the following:
- ___ I wish to receive all available life-sustaining treatments, including but not limited to mechanical ventilation, resuscitation, and artificial nutrition and hydration.
- ___ I wish to decline life-sustaining treatment if it is deemed that my condition is irreversible and will not improve.
- ___ My wishes regarding artificial nutrition (feeding tube) and hydration: ____________________________________
Pain Management and Comfort Care
I direct that treatment to alleviate pain or discomfort be provided at all times, even if it hastens my death:
___ Yes
___ No
Specific wishes regarding pain management and comfort care:
________________________________________________________________
Designation of Healthcare Proxy
In the event that I am unable to participate in my healthcare decisions, I designate the following individual as my healthcare proxy to make decisions on my behalf in accordance with my wishes and best interests:
Name: _____________________________________________________
Relationship: _____________________________________________
Primary Phone: ____________________________________________
Alternate Phone: __________________________________________
If the above-named person is unable or unwilling to serve as my healthcare proxy, I designate the following individual as an alternate:
Name: _____________________________________________________
Relationship: _____________________________________________
Primary Phone: ____________________________________________
Alternate Phone: __________________________________________
Organ and Tissue Donation
I express my wishes regarding organ and tissue donation as follows:
- ___ I wish to donate only the following organs/tissues: _________________________________
- ___ I wish to donate any needed organs or tissues.
- ___ I do not wish to donate any organs or tissues.
Final Statements
This Living Will represents my wishes as to my healthcare. It revokes any prior directives, oral or written. I understand the full import of this document, and I am emotionally and mentally competent to make this Living Will.
Signature
_______________________________________ Date: ____________________
(Signature)
This document was signed in the presence of:
Witness 1
_______________________________________ Date: ____________________
Name: ___________________________________________________________
Address: ________________________________________________________
Witness 2
_______________________________________ Date: ____________________
Name: ___________________________________________________________
Address: ________________________________________________________
This Living Will is executed voluntarily and without any form of pressure or influence from others. My signing evidences my understanding and acceptance of its contents and intentions.