Living Will Instructions
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In the event that the time comes and I am incapacitated to the point that I am no longer able to
actively take part in decisions for my own life, and I am unable to direct my healthcare physician
as to my own medical care, I hereby authorize this Living Will as my Advance Health Care
Directive to stand as a testament of my wishes.
I, ________________________, residing at ________________________,
________________________ in the County of ________________________ in the State of
________________________ in the zip code ________________________ and whose telephone
number is ________________________, being of sound mind, and acting willingly and without
duress, fraud or undue influence, herein direct that the instructions provided herein are to be
recognized as a formal statement of my desires with regards to my health care, custody and medical
treatment, and as such I hereby voluntarily declare and make this designation with regards to my
Living Will (aka Advance Health Care Directive and/or Health Care Proxy). These instructions
and directives shall be binding upon all involved to the fullest extent allowable by law.
I herein designate ________________________, residing at ________________________,
________________________, ________________________ ________________________ and
whose telephone number is ________________________, as my advocate and agent to make any
and all health care decisions on my behalf should I ever be diagnosed with a terminal illness,
disease, injury, or should I become incapacitated or permanently unconscious (in a coma or
persistent vegetative condition) where I would remain permanently unable to make decisions.
My health care advocate or agent shall have the power to make health care, custody and medical
treatment decisions on my behalf if my attending and/or primary physician makes the
determination that I am unable to make said decisions.
I have specific directives regarding the delivery of medical care in certain health care conditions.
Therefore, I wish to direct my medical treatment by way of the following conditions:
Should any of the aforementioned events occur, I wish to leave the following directives regarding
the treatment and procedures which may be used, withheld or withdrawn:
- I wish to ________________________ cardiac resuscitation (CPR) in an attempt to try and
prolong my life.
- I wish to ________________________ life-support (e.g., respirators, ventilators) used in
an effort to replace or support my natural breathing.
- I wish to ________________________ tube feeding or any other artificial or invasive form
of nutrition (food) or hydration (water).
- I wish to ________________________ blood or blood products.
- I wish to ________________________ any form of surgery or invasive diagnostic tests.
- I wish to ________________________ kidney dialysis.
- I wish to ________________________ antibiotics or medication in an attempt to try and
prolong my life.
I understand that if I do not specifically indicate my preferences above regarding any of the forms
of treatment, I may be subjected to that form of treatment.
With regards to the aforementioned medical situations outlined above, I herein provide the
following directives pertaining to the comfort care and pain relief:
- I wish to ________________________ maximum pain relief medication.
- I wish to ________________________ maximum pain relief medication if it may
unintentionally hasten my death.
- I wish to ________________________ maximum pain relief medication if it may result
in temporary addiction should I survive, recover or rebound from my current conditions
and/or extended hospital stay.
My appointed advocate or agent shall make health care decisions on my behalf in accordance with
my other wishes known to my advocate and/or agent. To the extent that my wishes are not known
to my advocate or agent, my advocate or agent shall make the necessary health care decisions for
me in accordance to what my advocate deems to be in my best interest. In determining those best
interests, my advocate shall take into consideration my personal values to the extent known to the
I direct my health care advocate, health care provider and others who may be involved in my health
care, to withhold or withdraw treatment in accordance with the choice I have indicated below:
This instrument shall be governed by the laws of ________________________, and I respectfully
request that it be honored in any state in which I may reside at the time that this Living Will shall
take effect.
By signing below, I certify that I am fully aware and completely understand the contents of this
document, and that I am of sound body and mind. Furthermore, I am of the legal age of consent
and not under undue influence, fraud or duress.
This Living Will (aka Advance Health Care Directive and/or Health Care Proxy) must be signed
by two adult witnesses that are personally present when I sign this document.
I certify that I am of 18 years of age or older and that I know the Declarant personally or have been
provided with valid identification to his/her identity and believe him/her to be of sound mind and
under no duress, fraud or undue influence. The Declarant has had the opportunity to read this
document and has signed or acknowledged his/her signature or mark in my presence.
Under penalty of perjury I declare that I am not related to the Declarant by blood, marriage or
adoption, nor am I responsible for his/her medical care or costs. Furthermore, I am not the primary
or attending physician or an employee of the physician or other health care provider or current care
facility for the Declarant. I also attest that I am not an employee of any life or health insurance
provider, nor am I involved with the direct physical care of the Declarant. Further, I have no claim
to the Declarant's estate, and to the best of my knowledge, I am not entitled to any part of the
Declarant's estate upon his/her death with any will now in existence or by any other process of
__________________________________________________________ __________________
(Declarant Signature) (Date)
_______________________________________ _________________
(Witness Signature) (Date)
________________________, ________________________
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______________________________________ _________________
(Witness Signature) (Date)
________________________, ________________________
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STATE OF ________________________
COUNTY OF ________________________
On this date, ___________________________, the Declarant, ________________________,
personally appeared before me and having provided verifiable identification to be the Declarant
whose name is subscribed to this instrument and acknowledged to me that s/he executed the same
in his/her capacity, and that by his/her signature on the instrument, executed the instrument.
I declare that s/he appears to be of sound mind and not under or subject to duress, fraud or undue
influence, that s/he acknowledges the execution the same to be his/her voluntary act and deed, and
that I am not the advocate, attorney-in-fact, proxy, surrogate, or a successor of any such, as
designated within this document, nor do I hold any interest in his/her estate through a Will or by
any other means or process of law.
WITNESS my hand and seal.
(Notary Signature)
My Commission Expires: _______________________________
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