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This required section states the circumstances under which life-sustaining procedures or treatment will be withheld or withdrawn, and includes an optional "coma" provision.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section in which the Declarant states whether artificially administered nutrition and hydration should be withheld or withdrawn.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 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 or notary in accordance with state law requirements. Press [Ctrl+F1] for more information.
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Living Will
LIW_KS
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declares his/her intention that withholding or withdrawal of life-sustaining procedures should be withheld or withdrawn under certain circumstances.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.
WKS01
! Declaration Section (1 of 9)
DECLARATION
Declaration made this _____ day of _______________, 19___.
I, !, being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged 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.
LMA02
! Life Support Section (2 of 9)
If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition
! [optional COMA provision] or a permanently unconscious condition
by two physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life-sustaining procedures are utilized,
! [automatically included if COMA checkbox is marked] or that I will remain in a permanently unconscious condition,
and where the application of life-sustaining 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 administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care.
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 permanently unconscious. Press [Ctrl+F1] for more information.
Enter an X if you want to have life-sustaining procedures or treatment withheld or withdrawn if you become permanently unconscious. Press [Ctrl+F1] for more information.
WKS03
! Optional Nutrition Section (3 of 9)
If I have a condition stated above, it is my preference
! TO RECEIVE artificially administered nutrition and hydration (food and fluids).
! NOT TO RECEIVE artificially administered nutrition and hydration (food and fluids), except as deemed necessary to provide me with comfort care.
Enter an X to include a paragraph that states whether you wish to receive or not to receive artificial nutrition and hydration if you are terminally ill or permanently unconscious. Press [Ctrl+F1] for more information.
Enter an X if you WISH TO RECEIVE artificially administered nutrition and hydration, even though your physicians certify that you have a terminal or permanently unconscious condition.
Enter an X if you DO NOT WISH TO RECEIVE artificially administered nutrition and hydration if your physicians certify that you have a terminal or permanently unconscious condition.
LAL04
! Optional Pregnancy Section (4 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-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 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.
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.
WKS07
! Right of Refusal Section (7 of 9)
In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this declaration shall be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such 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.
WKS08
! Declarant Signature Section (8 of 9)
I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration.
________________________________________
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.
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.
WKS09
! Witness Signature Section (9 of 9)
[This document requires the signature of two witnesses or a Notary Public.]
! [WITNESS BLOCK]
The Declarant has been personally known to me and I believe the Declarant 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 related to the Declarant by blood or marriage, entitled to any portion of the estate of the Declarant according to the laws of Intestate Succession or under any will or codicil of the Declarant, or directly financially responsible for the Declarant's medical care. I am at least 18 years of age.
This instrument was acknowledged before me on the _____ day of _______________, 19___, by
________________________________________
Notary Public
(Seal, if any)
My appointment expires: _________________________
This document requires the signature of two witnesses or a Notary Public. By signing this section, the persons declare that they were present when the Declarant signed this document. Note the limits on who may serve as a witness. Press [Ctrl+F1] for more information.
Enter an X if two witnesses will be signing the document. By signing this section, the persons declare that they were present when the Declarant signed this document. Note the limits on who may serve as a witness. Press [Ctrl+F1] for more information.
Enter the name of the FIRST witness 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.
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 name of the SECOND witness 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.
Enter an X if a Notary Public will be signing the document. The program completes the Declarant's name by transferring the information from a previous section. You may modify the information only by returning to that section. Press [Ctrl+F1] for more information.
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