INDIANA LIVING WILL DECLARATION
State Form 55316 (6-13)
Indiana State Department of Health – IC 16-36-4
This declaration is effective on the date of execution and remains in effect until revocation or the
death of the declarant. This declaration should be provided to your physician.
LIVING WILL DECLARATION
Declaration made this day of (month, year). I, ,
being at least eighteen (18) years of age and of sound mind, willfully and voluntarily make known my desires that my
dying shall not be artificially prolonged under the circumstances set forth below, and I declare:
If at any time my attending physician certifies in writing that:
(1) I have an incurable injury, disease, or illness;
(2) my death will occur within a short time; and
(3) the use of life prolonging procedures would serve only to artificially prolong the dying process,
I direct that such procedures be withheld or withdrawn and that I be permitted to die naturally with only the
performance or provision of any medical procedure or medication necessary to provide me with comfort care or to
alleviate pain, and, if I have so indicated below, the provision of artificially supplied nutrition and hydration.
(Indicate your choice by initialing or making your mark before signing this declaration.):
__________ I wish to receive artificially supplied nutrition and hydration, even if the effort to sustain
life is futile or excessively burdensome to me.
__________ I do not wish to receive artificially supplied nutrition and hydration, if the effort to sustain
life is futile or excessively burdensome to me.
__________ I intentionally make no decision concerning artificially supplied nutrition and hydration,
leaving the decision to my health care representative appointed under IC 16-36-1-7 or
my attorney in fact with health care powers under IC 30-5-5.
In the absence of my ability to give directions regarding the use of life prolonging procedures, it is my intention that
this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or
surgical treatment and accept the consequences of the refusal.
I understand the full import of this declaration.
Signed
City, County, and State of Residence
WITNESSES
The declarant has been personally known to me and I believe (him/her) to be of sound mind. I did not sign the
declarant's signature above for or at the direction of the declarant. I am not a parent, spouse, or child of the
declarant. I am not entitled to any part of the declarant's estate or directly financially responsible for the declarant's
medical care. I am competent and at least eighteen (18) years of age.
Witness __________________________________ Date (month, day, year) _____________________
Witness __________________________________ Date (month, day, year) _____________________
