"LIVING WILL"
Living Will made this
day of .
(Month, Year)
I,
, being of sound mind, willfully and
voluntarily make known my desire that my life should not be prolonged under the
circumstances set forth below and do declare:
Check each condition listed below in which you want the Living Will to apply:
1. If at any time I should
develop a terminal condition,
decline into a persistent comatose condition with no reasonable expectation of
regaining consciousness, or
decline into a persistent vegetative condition with no reasonable expectation of
regaining significant cognitive function,
as defined in and established in accordance with the procedures set forth in paragraphs
(2), (9), and (13) of Code Section 31-32-2 of the Official Code of Georgia Annotated, I
direct that the application of life-sustaining procedures to my body be withheld or
withdrawn and that I be permitted to die;
Check only one option from below:
I intend for "life-sustaining procedures" to also include nourishment and hydration. I want
to be permitted to die and want the following life-sustaining procedure(s) withheld or
withdrawn from me:
(I do not want to receive food or water)
(I do not want to receive food but I want
to receive water)
(I do not want to receive water but
I want
to receive food)
nourishment and hydration;
nourishment but not hydration;
hydration but not nourishment; or
neither nourishment nor hydration.
(I want to receive both food and water)
2.
In the absence of my ability to give
directions regarding the use of such life
sustaining procedures, it is my intention that this Living Will shall be honored by my
family and physician(s) as the final expression of my legal right to refuse medical or
surgical treatment and accept the consequences from such refusal;
3. I understand that I may revoke this Living Will at any time;
4.
I understand the full import of this Livi
ng Will, and I am at least 18 years of age,
and am emotionally and mentally competent to make this Living Will; and
5.
If I am female and I have been diagno
sed as pregnant, this Living Will shall have no
force and effect unless the fetus is not viable and I indicate by initialing after this
sentence that I want this Living Will to be carried out.
(Initial here)
_________________________________________________________________
Signature
_________________________________________________________________
City
_________________________________________________________________
County
_________________________________________________________________
State
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signature
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I hereby witness this Living Will and attest that:
1.
The declarant is personally known to me
and I believe the declarant to be at least 18
years of age and of sound mind:
2. I am at least 18 years of age:
3.
To the best of my knowledge, at the time
of the execution of this Living Will, I:
A. am not related to the declarant by blood or by marriage;
B.
would not be entitled to any portion of
the above person's estate by any will or by
operation of law under the rules of descent and distribution of this state;
C. am not the attending physician of declarant or an employee of the attending
physician or an employee of the hospital or skilled nursing home facility in which the
declarant is a patient;
D. am not directly financially responsible for the declarant's medical care; and
E. have no present claim against any portion of the estate of the declarant.
4.
Declarant has signed this document in my
presence as above instructed, on the date
above first shown.
Witness
Address
Witness
Address
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signature
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signature
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An additional witness is required when a Living Will is signed
in a hospital or skilled nursing facility.
This witness is required by law to be the:
Medical director of the skilled nursing facility or staff
physician not participating in care of the patient or Chief of
the hospital medical staff or staff physician or hospital
designee not participating in care of the patient.
I hereby witness this Living Will and attest that I believe the declarant to be of sound
mind and to have made this Living Will willingly and voluntarily.
Witness
Title/Position of Witness
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signature
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This is a replication of the Living Will form as found in the Georgia Code '31-32-4 as of
May 2002 with modifications. It is provided to the people of Georgia for their education
and information and is not intended as legal advice.
If you have questions about the law or about any part of this information, contact the:
Georgia Division of Aging Services
2 Peachtree Street, NW
Suite 9.398
Atlanta, Georgia 30303-3142
(404) 657-5258
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