Example of Living Will
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To all my family, doctors, surgeons, hospital, medical providers, and all other medical care persons:
I, [Name], being of sound mind and logical thought, willfully and voluntarily make this declaration to be followed should I become incapacitated or unable to express my own decisions regarding my own medical treatment.
This declaration represents my informed, firm and settled commitment to refuse any life-sustaining treatment under the circumstances listed below.
This declaration and the following instructions are a statement of my legal right to refuse life-sustaining medical treatment or care. I trust the parties mentioned to consider themselves as morally and legally bound to act in accordance to my wishes and preferences. The mentioned parties should then be free of any liabilities legal or otherwise for having followed this declaration and the directions that it contains.
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Directions
- I instruct my attending doctors or primary care givers to withhold or withdraw any life-sustaining medical care or treatment that is only serving to prolong the process of my death should I be in an incurable or irreversible physical or mental condition with no medical expectation of recovery.
- I instruct that treatment be limited to methods which are designed to keep me in comfort and free of pain, including any pain which might result from withholding or withdrawing any life sustaining medical treatment.
- I instruct that if I am in any of the conditions described in item 1, that it be remembered that I specifically DO NOT want the following types of medical care or treatment:
- ___________________________
- ___________________________
- ___________________________
- ___________________________
- ___________________________
- ___________________________
- ___________________________
- ___________________________
- I instruct that if I am in any of the conditions described in item1, that it be remembered that I specifically DO want the following types of medical care or treatment:
- ___________________________
- ___________________________
- ___________________________
- ___________________________
- ___________________________
- ___________________________
- ___________________________
- ___________________________
- I instruct that if I am in the condition described in item 1, and if I have the affliction or afflictions of the following disease, illness or injury, that I receive the following medical treatment and care:
This Living Will Declaration is made the __________day of __________, 20__________.
______________________________________________________
Signature
Witness Statements
I declare that the persons who have signed this document are personally known to me, that the undersigned have acknowledged this Living Will Declaration in my presence, and that the undersigned are of sound mind and are under no duress, fraud or other influence.
___________________________________ Date___________________
Witness Signature
___________________________________ Date___________________
Witness Signature
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