This is a required section in which the Declarant (the person the Living Will is prepared for) states his/her intention to make a Living Will. Press [Ctrl+F1] for more information.
This required section states the circumstances under which life-sustaining procedures or treatment will be withheld or withdrawn, and includes an optional "coma" provision. Press [Ctrl+F1] for more information.
This is an optional section in which the Declarant states whether artificially administered nutrition and hydration should be withheld or withdrawn. Press [Ctrl+F1] for more information.
This optional section states what effect should be given to the Living Will if the Declarant is pregnant. Press [Ctrl+F1] for more information.
This is an optional section which allows for additional specific instructions and requests. Press [Ctrl+F1] for more information.
This optional section designates a "Proxy" to make health care decisions if the Declarant is unable to do so. Press [Ctrl+F1] for more information.
This recommended provision provides that the inclusion of an invalid request or instruction does not invalidate the other provisions. Press [Ctrl+F1] for more information.
This is a required section which provides an opportunity for the Declarant to request that the provisions of this document be honored. Press [Ctrl+F1] for more information.
This required section provides the signature line for the Declarant who must sign in the presence of witnesses. Press [Ctrl+F1] for more information.
This required section provides signature lines for the witnesses in accordance with state law requirements. Press [Ctrl+F1] for more information.
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Living Will
LIW_ID
A Living Will is a document under which a competent adult, prior to becoming unconscious or incompetent, declares his/her intention that withholding or withdrawal of life-sustaining procedures should be withheld or withdrawn under certain circumstances
A Living Will is prepared for a "Declarant". Enter the Declarant's name or edit the information as desired. A Living Will directs the Declarant's physician to withdraw or withhold life-sustaining procedures if the Declarant is in a terminal condition with no hope of recovery. Press [Ctrl+F1] for more information.
WID01
! Declaration Section (1 of 10)
A LIVING WILL
A Directive to Withhold or to Provide Treatment
To my family, my relatives, my friends, my physicians, my employers, and all others whom it may concern:
Directive made this _____ day of _______________, 19___.
I, !, being of sound mind, willfully and voluntarily make known my desire that my life shall not be prolonged artificially under the circumstances set forth below, do hereby declare:
A Living Will is prepared for a "Declarant". In this required section, the Declarant states his/her intentions regarding life-sustaining procedures or treatment during terminal and/or coma circumstances.
A Living Will is prepared for a "Declarant". Enter the Declarant's name or edit the information as desired. A Living Will directs the Declarant's physician to withdraw or withhold life-sustaining procedures if the Declarant is in a terminal condition with no hope of recovery. Press [Ctrl+F1] for more information.
WID02
! Life Support Section (2 of 10)
If at any time I should have an incurable injury, disease, illness or condition certified to be terminal by two medical doctors who have examined me, and where the application of life-sustaining procedures of any kind would serve only to prolong artificially the moment of my death, and where a medical doctor determines that my death is imminent, whether or not life-sustaining procedures are utilized,
! [optional COMA provision] or I have been diagnosed as being in a persistent vegetative state,
I direct that the following expression of my intent be followed and that I be permitted to die naturally, and that I receive any medical treatment or care that may be required to keep me free of pain or distress.
This required section describes the circumstances under which you, the Declarant, want to have life-sustaining procedures or treatment withheld or withdrawn if you become terminally ill or are in a persistent vegetative state (permanently unconscious). Press [Ctrl+F1] for more information.
Enter an X if you want to have life-sustaining procedures or treatment or withheld or withdrawn if you become permanently unconscious. Press [Ctrl+F1] for more information.
WID03
! Nutrition/Hydration Section (3 of 10)
If at any time I should become unable to communicate my instructions,
! [full medical treatment requested] then I direct that all medical treatment, care, and nutrition and hydration necessary to restore my health, sustain my life, and to abolish or alleviate pain or distress be provided to me. Nutrition and hydration shall not be withheld or withdrawn from me if I would die from malnutrition or dehydration rather than from my injury, disease, illness or condition.
! [artificial nutrition and hydration requested] and where the application of artificial life-sustaining procedures shall serve only to prolong artificially the moment of my death, I direct such procedures be withheld or withdrawn except for the administration of nutrition and hydration.
! [artificial nutrition and hydration NOT requested] and where the application of artificial life-sustaining procedures shall serve only to prolong artificially the moment of death, I direct such procedures be withheld or withdrawn including withdrawal of the administration of nutrition and hydration.
This required section allows you to state your wishes regarding medical treatment, including the use of artificial nutrition and hydration if you are terminally ill or permanently unconscious. Press [Ctrl+F1] for more information.
Enter an X to request full medical treatment, including nutrition and hydration. Press [Ctrl+F1] for more information.
Enter an X to request the withholding or withdrawal of all life-sustaining procedures or treatment except artificial nutrition and hydration, if your physicians certify that you have a terminal or permanently unconscious condition.
Enter an X to request the withholding or withdrawal of any life-sustaining procedures or treatment, including artificially administered nutrition and hydration, if your physicians certify that you have a terminal or permanently unconscious condition.
LAL04
! Optional Pregnancy Section (4 of 10)
If I have been diagnosed as pregnant and that diagnosis is known to my physician, this document shall have no force or effect during the course of my pregnancy.
! [Optional additional sentence] However, if at any point it is determined that it is not possible that the fetus could develop to the point of live birth with continued application of life-sustaining procedures, it is my preference that this document be given effect at that point.
! [Optional additional sentence] If life-sustaining procedures will be physically harmful or unreasonably painful to me in a manner that cannot be alleviated by medication, I request that my desire for personal physical comfort be given consideration in determining whether this document shall be effective if I am pregnant.
Enter an X to include a pregnancy section which states that this Living Will will not be enforced if you are pregnant. Certain exceptions to this statement are presented. Press [Ctrl+F1] for more information.
Enter an X to provide an exception to the invalidity of the Living Will if you are pregnant. This exception permits enforcement of the Living Will if the fetus could not develop to the point of live birth with the continued application of life-sustaining procedures.
Enter an X to provide an exception to the invalidity of the Living Will if you are pregnant. This exception requests that pain or physical harm to you be considered in determining whether life-sustaining procedures or treatment should be withheld or withdrawn.
LAL05
! Optional Other Specific Requests Section (5 of 10)
Other specific requests:
Enter an X to include a paragraph that allows you to state other specific requests or instructions.
Use this space to state any other specific requests or instructions.
WID06
! Optional Proxy Section (6 of 10)
[If this option is selected, a Durable Power of Attorney for Health Care must also be signed.]
In the absence of my ability to give directions regarding the use of life-sustaining procedures, I hereby appoint !,
currently residing at
!, ! !,
! , !
as my Attorney-in-fact/Proxy for the making of decisions relating to my health care in my place.
! If he or she is not reasonably available, is unwilling to serve, or if I revoke his or her authority to act as my Attorney-in-fact/Proxy, I appoint !,
currently residing at
!, ! !,
! , !,
as my Attorney-in-fact/Proxy for the making of decisions relating to my health care in my place.
It is my intention that this appointment shall be honored by my Attorney-in-fact/Proxy, and by my family, relatives, friends, physicians and lawyer as the final expression of my legal right to refuse medical or surgical treatment; and I accept the consequences of such a decision. I HAVE DULY EXECUTED A DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS ON THIS DATE.
[WARNING: The Idaho Natural Death Act requires that a separate Durable Power of Attorney for heath care decisions be properly completed, if this option is selected. This program's "Health Care Power of Attorney" document will provide you with the necessary form.]
Enter an X to include a section that allows you to designate someone as a "Health Care Proxy" to make health care decisions for you if you are unable to do so. Press [Ctrl+F1] for more information.
Enter the Proxy's name or use the P.I. Manager to select and paste a record.
Enter the Proxy's street address or edit the information as desired.
Enter the Proxy's extended street address or edit the information as desired.
Enter the Proxy's city or edit the information as desired.
Enter the Proxy's state/province or edit the information as desired.
Enter the Proxy's zip/postal code or edit the information as desired.
Enter an X to include the country in which the Proxy resides, if outside the United States.
Enter the country or edit the information as desired.
Enter an X if you wish to designate an Alternate Proxy if the original Proxy refuses or is unable or unavailable to act on your behalf.
Enter the Alternate Proxy's name or use the P.I. Manager to select and paste a record.
Enter the Alternate Proxy's street address or edit the information as desired.
Enter the Alternate Proxy's extended street address or edit the information as desired.
Enter the Alternate Proxy's city or edit the information as desired.
Enter the Alternate Proxy's state/province or edit the information as desired.
Enter the Alternate Proxy's zip/postal code or edit the information as desired.
Enter an X to include the Alternate Proxy's country, if outside the United States.
LAL06
! Optional Severability Section (7 of 10)
If any provision in this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
It is recommended that this severability provision be included to prevent one invalid provision from invalidating the entire document. However, if you do not want to include it, press the spacebar to deselect the checkbox. Press [Ctrl+F1] for information regarding the reasons for including a severability paragraph.
WID08
! Right of Refusal Section (8 of 10)
In the absence of my ability to give further directions regarding my treatment, including life-sustaining procedures, it is my intention that this directive shall be honored by my family and physicians as the final expression of my legal right to refuse or accept medical and surgical treatment, and I accept the consequences of such refusal.
I understand the full importance of this directive and am emotionally and mentally competent to make this directive. No participant in the making of this directive or in its being carried into effect, whether it be a medical doctor, my spouse, a relative, friend or any other person, shall be held responsible in any way, legally, professionally or socially, for complying with my directions.
This required section states the Declarant's request that the Living Will be followed. It also notes the Declarant's basic right to make medical decisions, including the right to refuse treatment.
WID09
! Declarant Signature Section (9 of 10)
________________________________________
Signature
Declarant Name: !
Declarant Address:City: !
County: ! County
State: !
! Country: !
! SSN: !
! Birthdate: !
This required section provides a signature line for the Declarant, and requests additional information regarding the Declarant. Press [Enter] to go to the first entry field.
Enter the Declarant's city or edit the information as desired.
Enter the Declarant's county/parish or edit the information as desired.
Enter the Declarant's state/province or edit the information as desired.
Enter an X to include the country in which the Declarant resides, if outside the United States.
Enter the country or edit the information as desired.
Enter an X to include the Declarant's social security number (SSN). By providing the SSN, the health care providers will be assisted in maintaining their Living Will files. Press [Ctrl+F1] for more information.
Enter the Declarant's social security number or edit the information as desired.
Enter an X to include the Declarant's date of birth. By providing the date of birth, the health care providers will be assisted in maintaining their Living Will files. Press [Ctrl+F1] for more information.
Using the format MM/DD/YYYY, enter the Declarant's date of birth or edit the information as desired.
WID10
! Witness Signature Section (10 of 10)
The Declarant has been known to me personally and I believe him/her to be of sound mind.
This required section provides signature lines for the witnesses, and requests additional information regarding the witnesses. Press [Enter] to go to the first entry field.
Enter the FIRST witness' name or use the P.I. Manager to select and paste a record. The witness information may be left blank and be completed when the document is signed. Press [Ctrl+F1] for more information.
Enter the witness' street address or edit the information as desired.
Enter the witness' extended street address or edit the information as desired.
Enter the witness' city or edit the information as desired.
Enter the witness' state/province or edit the information as desired.
Enter the witness' zip/postal code or edit the information as desired.
Enter an X to include the witness' country, if outside the United States.
Enter the country or edit the information as desired.
Enter the SECOND witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
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