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This required section states the circumstances under which life-sustaining procedures will be withheld or withdrawn if the Declarant's death is imminent. Press [Ctrl+F1] for more information.
This required section states the circumstances under which life-sustaining procedures will be withheld or withdrawn if the Declarant is in a coma. 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 optional section permits the Declarant to make anatomical gifts and state that life sustaining procedures may be used until organ donations can be made
This optional section 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 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_MD
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declares his/her intention that withholding or withdrawal of life-sustaining procedures should be withheld or withdrawn under certain circumstances.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.
WMD01
! Declaration Section (1 of 9)
LIVING WILL
If I, !, am not able to make an informed decision regarding my health care, I direct my health care providers to follow my instructions as set forth below.
A Living Will is prepared for a "Declarant". This required section includes the name of the Declarant and an opening statement. Press [Ctrl+F1] for more information.
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.
WMD02
! Terminal Condition Section (2 of 9)
A. If my death from a terminal condition is imminent, and even if life-sustaining procedures are used there is no reasonable expectation of my recovery,
! I direct that my life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artificially.
! I direct that my life not be extended by life-sustaining procedures, except that, if I am unable to take in food by mouth, I wish to receive nutrition and hydration artificially.
! I direct that, even in a terminal condition, I be given all available medical treatment in accordance with accepted health care standards.
This required section allows the Declarant to state whether life-sustaining treatment should be withheld or withdrawn if the Declarant's death is expected to occur imminently. Press [Ctrl+F1] for more information.
Enter an X if all life-sustaining procedures should be withheld or withdrawn, including the withholding or withdrawal of artificial nutrition and hydration. Press [Ctrl+F1] for more information regarding artificial nutrition and hydration.
Enter an X if life-sustaining procedures should be withheld or withdrawn, except that artificial nutrition and hydration should be provided. Press [Ctrl+F1] for more information regarding life sustaining procedures.
Enter an X if the Declarant wishes to receive all available medical treatment, even if the Declarant's death is expected to occur imminently. Press [Ctrl+F1] for more information regarding the definition of a terminal condition.
WMD03
! Coma Section (3 of 9)
B. If I am in a persistent vegetative state, that is, if I am not conscious and am not aware of my environment nor able to interact with others, and there is no reasonable expectation of my recovery within a medically appropriate period,
! I direct that my life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artificially.
! I direct that my life not be extended by life-sustaining procedures, except that, if I am unable to take in food by mouth, I wish to receive nutrition and hydration artificially.
! I direct that I be given all available medical treatment in accordance with accepted health care standards.
This required section allows the Declarant to state whether life-sustaining treatment should be withheld or withdrawn if the Declarant is in a persistent vegetative state (permanent coma). Press [Ctrl+F1] for more information.
Enter an X if all life-sustaining procedures should be withheld or withdrawn, including the withholding or withdrawal of artificial nutrition and hydration. Press [Ctrl+F1] for more information regarding artificial nutrition and hydration.
Enter an X if life-sustaining procedures should be withheld or withdrawn, except that artificial nutrition and hydration should be provided. Press [Ctrl+F1] for more information regarding life sustaining procedures.
Enter an X if the Declarant wishes to receive all available medical treatment, even though the Declarant is not expected to recover from the persistent vegetative state (permanent coma). Press [Ctrl+F1] for more information regarding the definition of a permanent coma.
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.
WMD05
! Optional Donation of Organs Section (5 of 9)
I give
! my body
! any needed organs, tissues, or parts
! except
! the following organs, tissues, or parts:
! to the following named physician, hospital, tissue bank, or other medical institution:
! for any purpose authorized by law.
! for the following purposes:
! transplantation
! therapy
! medical research
! education
! _______________________________________
purposes.
Notwithstanding the other provisions of this document, if I have been determined to be dead according to law, I direct my attending physician to maintain my organs on artificial support systems only for the period of time required to maintain the viability of and to remove the donated organs and/or tissues.
Enter an X to include an optional section which allows the Declarant to make an organ donation, and to designate which organs, tissues, or parts the Declarant desires to donate at the Declarant's death. Press [Ctrl+F1] for more information.
Enter an X if the Declarant desires to donate his or her body at the Declarant's death.
Enter an X if the Declarant desires that any needed organs, tissues, or parts be donated at the Declarant's death.
Enter an X to list one or two specific organs that the Declarant does NOT want removed at death.
Enter a description of the specific organs, tissues, or parts that should not be removed from the Declarant's body at death. For example, enter the word "heart" or "eyes".
Enter an X if the Declarant desires to specify only selected organs, tissues, or parts to be removed upon the Declarant's death.
Enter a description of the selected organs, tissues, or parts to be removed upon the Declarant's death. For example, heart, heart valves, lungs, kidneys, liver, pancreas, intestines, bone, skin, blood vessels, eyes, musculoskeletal structures or body fluids.
Enter an X to include a designation of an individual or institution to receive the donation. If this section is not included, the Declarant's organs and tissues will be given to individuals or institutions who can use them.
Enter the name of the individual or entity to receive the donated organs, tissues, or parts. Only certain individuals and institutions are authorized to accept organs and tissues. For more help, access Document Information regarding acceptable donees.
Enter an X if the Declarant desires to donate organs, tissues, or parts to be used for any purpose authorized by law.
Enter an X to state the purpose for which the donation may be used. Such purposes include: transplantation, therapy, medical research and education.
Enter an X if the Declarant desires the organs, tissues, or parts be used for transplantation.
Enter an X if the Declarant desires that the organs, tissues, or parts be used for therapy. Some organs and tissues provide essential treatment for patients who do not necessarily need a transplant.
Enter an X if the Declarant desires that the organs, tissues, or parts be used for research. Organs and tissues that are not suitable for transplantation or therapy are needed in medical research.
Enter an X if the Declarant desires that the organs, tissues, or parts be used for education. Donated organs and tissues can play an important role in medical education.
Enter an X if the Declarant directs that artificial support procedures may be used to maintain the Declarant's body until organization donation wishes can be met.
LAL05
! Optional Other Specific Requests Section (6 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 (7 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.
WMD08
! Declarant Signature Section (8 of 9)
By signing below, I indicate that I am emotionally and mentally competent to make this Living Will and that I understand its purpose and effect.
Date: ___________________
________________________________________
Signature
Declarant Name: !
Declarant Address:City: !
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 line at the time the document is signed.
Enter the Declarant's city 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.
WMD09
! 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 signed or acknowledged signing this Living Will in my presence and based upon my personal observation, the Declarant appears to be a competent individual. At least one of the undersigned witnesses is not knowingly entitled to any portion of the estate of the Declarant or knowingly entitled to any financial benefit by reason of the death of the Declarant.
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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