Fill - Free fillable Living Will Suggested form of a Living Will, PDF form

Suggested form of a Living Will, Florida Statutes Section 765.303

A living will may, BUT NEED NOT, be in the following form:

Living Will

Declaration made this day of 2 , I

willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances

set forth below, and I do hereby declare that, if at any time I am incapacitated and

I have a terminal condition.

or I have an end stage condition.

or I am in a persistent vegetative state,

and if my attending or treating physician and another consulting physician have determined that there is no reasonable

medical probability of my recovery from such condition, I direct that life-prolonging procedures be withheld or

withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and

that I be permitted to die naturally with only the administration of medication or the performance of any medical

procedure deemed necessary to provide me with comfort care or to alleviate pain.

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 to accept the consequences for such refusal.

In the event that I have been determined to be unable to provide express and informed consent regarding the

withholding, withdrawal, or continuation of life-prolonging procedures, I wish to designate, as my surrogate to carry

out the provisions of this declaration:

Name

Address

City State Zip

Phone

I understand the full import of this declaration, and I am emotionally and mentally competent to make this

declaration.

Additional Instructions (optional):

(Signed):

Witness

Street Address

City, State & Zip

Phone

Witness

Street Address

City, State & Zip

Phone

The principal’s failure to designate a surrogate shall not invalidate the living will.

— This form offered as a courtesy of The Florida Bar and the Florida Medical Association —

04/05

LIVING WILLS AND HEALTH CARE ADVANCE DIRECTIVES: FAQs

The Florida Legislature has recognized that every competent adult has the fundamental right of self-

determination regarding decisions pertaining to his or her own health, including the right to choose or

refuse medical treatment or procedures which would only prolong life when a terminal condition exists. This

right, however, is subject to certain interests of society, such as the protection of human life and the

preservation of ethical standards in the medical profession. To ensure that this right is not lost or

diminished by virtue of later physical or mental incapacity, the Legislature has established a procedure

within Florida Statutes Chapter 765 allowing a person to plan for incapacity, and if desired, to designate

another person to act on his or her behalf and make necessary medical decisions upon such incapacity.

What is a Living Will?

Every competent adult has the right to make a written declaration commonly known as a "Living Will." The

purpose of this document is to direct the provision, the withholding or withdrawal of life prolonging

procedures in the event one should have a terminal condition. The suggested form of this instrument has

been provided by the Legislature within Florida Statutes Section 765.303. In Florida, the definition of "life

prolonging procedures" has been expanded by the Legislature to include the provision of food and water

to terminally ill patients.

What is the difference between a Living Will and a legal will?

A Living Will should not be confused with a person’s legal will, which disposes of personal property on or

after his or her death, and appoints a personal representative or revokes or revises another will.

How do I make my Living Will effective?

Under Florida law, a Living Will must be signed by its maker in the presence of two witnesses, at least one

of whom is neither the spouse nor a blood relative of the maker. If the maker is physically unable to sign

the Living Will, one of the witnesses can sign in the presence and at the direction of the maker. Florida will

recognize a Living Will, which has been signed in another state, if that Living Will was signed in compliance

with the laws of that state, or in compliance with the laws of Florida.

After I sign a Living Will, what is next?

Once a Living Will has been signed, it is the maker's responsibility to provide notification to the physician

of its existence. It is a good idea to provide a copy of the Living Will to the maker's physician and hospital,

to be placed within the medical records.

What is a Health Care Surrogate?

Any competent adult may also designate authority to a Health Care Surrogate to make all health care

decisions during any period of incapacity. During the maker's incapacity, the Health Care Surrogate has

the duty to consult expeditiously, with appropriate health care providers. The Surrogate also provides

informed consent and makes only health care decisions for the maker, which he or she believes the maker

would have made under the circumstances if the maker were capable of making such decisions. If there

is no indication of what the maker would have chosen, the Surrogate may consider the maker's best

interest in deciding on a course of treatment. The suggested form of this instrument has been provided by

the Legislature within Florida Statutes Section 765.203.

How do I designate a Health Care Surrogate?

Under Florida law, designation of a Health Care Surrogate should be made through a written document,

and should be signed in the presence of two witnesses, at least one of whom is neither the spouse nor a

blood relative of the maker. The person designated as Surrogate cannot act as a witness to the signing of

the document.

Can I have more than one Health Care Surrogate?

The maker can also explicitly designate an Alternate Surrogate. The Alternate Surrogate may assume the

duties as Surrogate if the original Surrogate is unwilling or unable to perform his or her duties. If the maker

is physically unable to sign the designation, he or she may, in the presence of witnesses, direct that

another person sign the document. An exact copy of the designation must be provided to the Health Care

Surrogate. Unless the designation states a time of termination, the designation will remain in effect until

revoked by its maker.

Can the Living Will and the Health Care Surrogate designation be revoked?

Both the Living Will and the Designation of Health Care Surrogate may be revoked by the maker at any

time by a signed and dated letter of revocation; by physically canceling or destroying the original document;

by an oral expression of one's intent to revoke; or by means of a later executed document which is

materially different from the former document. It is very important to tell the attending physician that the

Living Will and Designation of Health Care Surrogate has been revoked.

Where can I go to obtain legal advice on this issue?

If you believe you need legal advice, call your attorney. If you do not have an attorney, call The Florida Bar

Lawyer Referral Service at 1-800-342-8011, or the local lawyer referral service or legal aid office listed in

the yellow pages of your telephone book.

This information has been prepared by the Consumer Protection Law Committee of The Florida

Bar and the Bar’s Public Information Office and is offered as a courtesy of The Florida Bar and the

Florida Medical Association.

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