MY LIVING WILL

 

THE KIND OF MEDICAL TREATMENT I WANT AND DONíT WANT IF I HAVE A TERMINAL CONDITION OR AM IN A PERSISTENT VEGETATIVE STATE.

 

Living will made this _____day of ____________, 20____

 

I ______________________________________, being of sound mind, willfully and voluntarily declare that I want my wishes to be respected if I am sick and not able to communicate my wishes for myself. In the absence of my ability to give directions regarding the use of life-prolonging medical intervention, it is my desire that my dying shall not be prolonged under the following circumstances:

 

If I am very sick and not able to communicate my wishes for myself and I am certified by one physician, who has personally examined me, to have a terminal condition or to be in a persistent vegetative state (I am unconscious and am neither aware of my environment nor able to interact with others), I direct that life-prolonging medical intervention that would serve solely to prolong the dying process or maintain me in a persistent vegetative state be withheld or withdrawn. I want to be allowed to die naturally and only be given medication or other medical procedures necessary to keep me comfortable. I want to receive as much medication as necessary to alleviate my pain.

 

I give the following SPECIAL DIRECTIVES OR LIMITATIONS: (Comments about tube feeding, breathing machines, cardiopulmonary resuscitation, dialysis and mental health treatment may be placed here. My failure to provide special directives or limitations does not mean that I want or refuse certain treatments.)

 

 

 

 

 

 

It is my intention that this living will be honored as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences resulting from such refusal.

 

I under the full import of this living will.

 

Signed: ________________________________

Address: ___________________________________   State ____________

 

(Witnessed):

I did not sign the principalís signature above for or at the direction of the principal. I am at least eighteen years of age and am not related to the principal by blood or marriage, entitled to any portion of the estate of the principal to the best of my knowledge under any will of principal or codicil thereto, or directly financially responsible for the principalís medical care. I am not the principalís attending physician or the principalís medical power of attorney representative or successor medical power of attorney representative under a medical power of attorney.

 

Witness: ___________________________ Date: ______________

Witness: ___________________________ Date: ______________

 

(Notarized)

State _____________________ County of ___________________

 

I _______________________ Notary Public of said county, do certify that ________________________________ as principal, and ____________________________

and ______________________, as witnesses, whose names are signed to the writing above bearing date on the ______ day of ______, 20___, have this day acknowledged the same before me.

 

Given under my hand this ____ day of ______, 20___.

 

My commission expires: ______________

________________________________________ Notary Public

 

 

 

SEAL