Living Will Template
This Living Will is made in accordance with the laws of the State of [Your State]. It expresses my wishes regarding medical treatment in the event that I am unable to communicate my preferences.
Personal Information
- Full Name: __________________________
- Date of Birth: _______________________
- Address: ____________________________
- Phone Number: ______________________
Healthcare Representative
If I become unable to make my own healthcare decisions, I appoint the following person as my healthcare representative:
- Full Name: __________________________
- Relationship: ________________________
- Address: ____________________________
- Phone Number: ______________________
Declarative Statements
In the event that I am diagnosed with a terminal condition, or I am in a persistent vegetative state, I do not wish for my life to be prolonged through the use of:
- Mechanical ventilation
- Dialysis
- Nutrition and hydration provided by tubes
- Other life-sustaining treatments: _______________
Should I be in such a condition, I request the following:
- Comfort care and pain relief should be prioritized.
- Do not resuscitate if my heart stops or I stop breathing.
Additional Instructions
If there are any other wishes or conditions, please specify here:
______________________________________________________________
______________________________________________________________
Signature
I understand that this Living Will reflects my wishes, and I voluntarily sign it.
Signature: ____________________________
Date: _________________________________
Witness Information
This document must be witnessed by two persons. My witnesses attest that I appeared to be of sound mind and voluntarily signed this document.
- Witness 1 Name: __________________________
- Witness 1 Signature: _____________________
- Witness 2 Name: __________________________
- Witness 2 Signature: _____________________