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This required section states the circumstances under which death-prolonging procedures will be withheld or withdrawn, and includes an optional "coma" provision.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section in which the Declarant states whether artificially administered nutrition and hydration should be withheld or withdrawn.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 required section states that this document is not intended to shorten the Declarant's life. This document's purpose is to permit a natural death. 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.
This is a required section which gives the Declarant the opportunity to revoke the Living Will at any time. Press [Ctrl+F1] for more information.
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Living Will
LIW_MO
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declares his/her intention that withholding or withdrawal of life-sustaining procedures should be withheld or withdrawn under certain circumstances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.
WMO01
! Declaration Section (1 of 10)
DECLARATION
[THIS DOCUMENT IS BEING PREPARED FOR !]
I have the primary right to make my own decisions concerning treatment that might unduly prolong the dying process. By this declaration I express to my physician, family and friends my intent.
A Living Will is prepared for a "Declarant". In this required section, the Declarant states his/her intentions regarding death-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.
WMO02
! Life Support Section (2 of 10)
If I should have a terminal condition
! [optional COMA provision] or a permanently unconscious condition
it is my desire that my dying not be prolonged by administration of death-prolonging procedures. If my condition is terminal and I am unable to participate in decisions regarding my medical treatment,
! [automatically included if COMA checkbox is marked] or if I am in a permanently unconscious condition,
I direct my attending physician to withhold or withdraw medical procedures that merely prolong the dying process and are not necessary to my comfort or to alleviate pain.
This is a required section. This section describes the circumstances under which you, the Declarant, want to have death-prolonging procedures 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 death-prolonging procedures withheld or withdrawn if you become permanently unconscious. Press [Ctrl+F1] for more information.
WMO03
! Optional Nutrition Section (3 of 10)
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 my comfort or to alleviate pain.
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.
WMO04
! 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 death-prolonging procedures, it is my preference that this document be given effect at that point.
! [Optional additional sentence] If death-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 the Declarant is 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 the Declarant is 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 death-prolonging procedures.
Enter an X to provide an exception to the invalidity of the Living Will if the Declarant is pregnant. This exception requests that pain or physical harm to the Declarant be considered in determining whether death-prolonging procedures 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.
LAL06
! Optional Severability Section (6 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.
WMO07
! Natural Death Section (7 of 10)
It is not my intent to authorize affirmative or deliberate acts or omissions to shorten my life rather only to permit the natural process of dying.
This required section states that the Declarant will not authorize specific acts which would result in a shortened life, but rather permit the process of natural death to occur.
WMO08
! Declarant Signature Section (8 of 10)
Signed this _____ day of _______________, 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.
WMO09
! Witness Signature Section (9 of 10)
[CAREFULLY REVIEW THE RESTRICTIONS ON WHO MAY BE A WITNESS. IF THE DOCUMENT IS NOT PROPERLY WITNESSED, IT MAY NOT BE ENFORCEABLE.]
The Declarant is known to me, is eighteen years of age or older, of sound mind and voluntarily signed this document in my presence. I am eighteen years of age or older.
This required section provides signature lines for the witnesses, and requests additional information regarding the witnesses. The date the document is signed should be entered on the blank lines at the time the document is signed.
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.
WMO10
! Revocation Section (10 of 10)
[THIS SECTION SHOULD ONLY BE SIGNED WHEN THE DECLARANT WISHES TO REVOKE THIS DOCUMENT.]
REVOCATION PROVISION
I hereby revoke the above declaration.
Signed: ___________________________________
(Signature of Declarant)
Date: ___________________________________
This is a required section which states the Declarant's revocation of the above declaration. Press [Ctrl+F1] for more information.
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