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This required section states the circumstances under which life-prolonging procedures will be withheld or withdrawn, and includes an optional "coma" provision and nutrition provision. 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.
Times New Roman
Living Will
LIW_IN
The 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declares his/her intention that withholding or withdrawal of life-sustaining procedures should be withheld or withdrawn under certain circumstances.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.
WIN01
! Declaration Section (1 of 9)
LIVING WILL DECLARATION
Declaration made this _____ day of _______________, 19___.
I, !, being at least eighteen (18) years old and of sound mind, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below, and I declare:
A Living Will is prepared for a "Declarant". In this required section, the Declarant states his/her intentions regarding life-prolonging procedures 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.
WIN02
! Life Support Section (2 of 9)
If at any time my attending physician certifies in writing that
(1) I have an incurable injury, disease, or illness
! [optional COMA provision] or a permanently unconscious condition;
(2) my death will occur within a short period of time
! [automatically included if COMA checkbox is marked] or that I will remain in a permanently unconscious condition;
and (3) the use of life-prolonging procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the performance or provision of any medical procedure or medication necessary to provide me with comfort care or to alleviate pain, and, if I have so indicated below, the provision of artificially supplied nutrition and hydration. (Indicate your choice by initialling or making your mark before signing this declaration):
[Access Document Information for an explanation regarding Artificial Nutrition/Hydration.]
______ (Initials) I wish to receive artificially supplied nutrition and hydration, even if the effort to sustain life is futile or excessively burdensome to me.
______ (Initials) I do not wish to receive artificially supplied nutrition and hydration, if the effort to sustain life is futile or excessively burdensome to me.
______ (Initials) I intentionally make no decision concerning artificially supplied nutrition and hydration, leaving the decision to my health care representative appointed under IC 16-36-1-7 or my attorney in fact with health care powers under IC 30-5-5.
This required section states whether you wish to receive or not to receive artificial nutrition or hydration or life-prolonging procedures if you become terminally ill or permanently unconscious. Press [Ctrl+F1] for more information.
Enter an X if you want to have life-prolonging procedures withheld or withdrawn if you become permanently unconscious. Press [Ctrl+F1] for more information.
LFL04
! Optional Pregnancy Section (3 of 9)
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-prolonging procedures, it is my preference that this document be given effect at that point.
! [Optional additional sentence] If life-prolonging 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 paragraph. This provision states that the 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-prolonging 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-prolonging procedures should be withheld or withdrawn.
LAL05
! Optional Other Specific Requests Section (4 of 9)
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.
WIN05
! Optional Representative Section (5 of 9)
If I am unable to make health care decisions for myself, I hereby appoint !,
currently residing at
!, ! !,
! , Country: !,
as my health care representative for the purpose of making decisions relating to my health care in my place.
! If the person I have named above refuses or is unable or unavailable to act on my behalf, or if I revoke that person's authority to act as my health care representative, I appoint!,
currently residing at
!, ! !,
! , Country: !,
as my health care representative for the purpose of making decisions relating to my health care in my place.
I authorize my health care representative to make decisions in my best interest concerning withdrawal or withholding of health care. If at any time, based on my previously expressed preferences and the diagnosis and prognosis, my health care representative is satisfied that certain health care is not or would not be beneficial, or that such health care is or would be excessively burdensome, then my health care representative may express my will that such health care be withheld or withdrawn and may consent on my behalf that any or all health care be discontinued or not instituted, even if death may result.
My health care representative must try to discuss this decision with me. However, if I am unable to communicate, my health care representative may make such a decision for me, after consultation with my physician or physicians and other relevant health care givers. To the extent appropriate, my health care representative may also discuss this decision with my family and others, to the extent they are available.
Enter an X to include a section that allows you to designate someone as a "Health Care Representative" to make health care decisions for you when you are unable to do so. Press [Ctrl+F1] for more information.
Enter the Representative's name or use the P.I. Manager to select and paste a record.
Enter the Representative's street address or edit the information as desired.
Enter the Representative's extended street address or edit the information as desired.
Enter the Representative's city or edit the information as desired.
Enter the Representative's state/province or edit the information as desired.
Enter the Representative's zip/postal code or edit the information as desired.
Enter an X to include the Representative's country, if outside the United States.
Enter the country or edit the information as desired.
Enter an X if you wish to designate an Alternate Health Care Representative if the original Health Care Representative refuses or is unable or unavailable to act on your behalf.
Enter the Alternate Health Care Representative's name or use the P.I. Manager to select and paste a record.
Enter the Alternate Health Care Representative's street address or edit the information as desired.
Enter the Alternate Health Care Representative's extended street address or edit the information as desired.
Enter the Alternate Health Care Representative's city or edit the information as desired.
Enter the Alternate Health Care Representative's state/province or edit the information as desired.
Enter the Alternate Health Care Representative's zip/postal code or edit the information as desired.
Enter an X to include the Alternate Health Care Representative's country, if outside the United States.
LAL06
! Optional Severability Section (6 of 9)
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.
WIN07
! Right of Refusal Section (7 of 9)
In the absence of my ability to give directions regarding the use of life-prolonging procedures, 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 accept the consequences of the refusal.
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.
WIN08
! Declarant Signature Section (8 of 9)
I understand the full import of this declaration.
Date Signed: _______________ _____, 19___.
________________________________________
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. The date of the document should be entered on the blank lines at the time the document is signed.
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.
WIN09
! Witness Signature Section (9 of 9)
[CAREFULLY REVIEW THE RESTRICTIONS ON WHO MAY BE A WITNESS. IF THE DOCUMENT IS NOT PROPERLY WITNESSED, IT MAY NOT BE ENFORCEABLE.]
The Declarant has been personally known to me, and I believe him/her to be of sound mind. I did not sign the Declarant's signature above for or at the direction of the Declarant. I am not a parent, spouse, or child of the Declarant. I am not entitled to any part of the Declarant's estate or directly financially responsible for the Declarant's medical care. I am competent and at least eighteen (18) years old.
This required section provides signature lines for the witnesses, and requests additional information regarding the witnesses.
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. Review the limits on who may be a witness. If the document is not properly witnessed, it may not be enforceable. 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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