This required section states whether or not the Declarant desires that life-prolonging treatments be withheld or withdrawn under certain circumstances. Press [Ctrl+F1] for more information.
This required section states the circumstances under which life-prolonging treatment will be withheld or withdrawn, and includes an optional "coma" provision.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 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_ND
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declares his/her intention that withholding or withdrawal of life-sustaining procedures should be withheld or withdrawn under certain circumstances.
WND01
! Declaration Section (1 of 7)
DECLARATION
I declare on the _____ day of ________________, 19____:
1. I have made the following decision concerning life-prolonging treatment (Initial your choice):
[The complete text of each selection is provided below]
! Life-prolonging treatment be withheld or withdrawn.
! Life-prolonging treatment be used.
! I make no statement concerning life-prolonging treatment.
! _____ (Declarant's initials) I direct that life-prolonging treatment be withheld or withdrawn and that I be permitted to die naturally if two physicians certify that:
(a) I am in a terminal condition that is an incurable or irreversible condition which, without the administration of life-prolonging treatment, will result in my imminent death;
(b) The application of life-prolonging treatment would serve only to artificially prolong the process of my dying; and
(c) I am not pregnant.
! ["coma" option] Or if two physicians certify that I am in a permanently unconscious condition which is reasonably concluded to be irreversible.
It is my intention that this declaration be honored by my family and physicians as the final expression of my legal right to refuse medical or surgical treatment and that they accept the consequences of that refusal, which is death.
! _____ (Declarant's initials) I direct that life-prolonging treatment, which could extend my life, be used if two physicians certify that I am in a terminal condition that is an incurable or irreversible condition which, without the administration of life-prolonging treatment, will result in my imminent death. It is my intention that this declaration be honored by my family and physicians as the final expression of my legal right to direct that medical or surgical treatment be provided.
! _____ (Declarant's initials) I make no statement concerning life-prolonging treatment.
A Living Will is prepared for a "Declarant". In this required section, the Declarant states his/her intentions regarding life-prolonging treatment during terminal and/or coma circumstances.
Enter an X if the Declarant desires that life-prolonging treatment be withdrawn or withheld if two physicians certify that the Declarant is in a terminal condition with no hope of recovery. Press [Ctrl+F1] for more information.
Enter an X if the Declarant desires that life-prolonging treatment NOT be withdrawn or withheld if two physicians certify that the Declarant is in a terminal condition with no hope of recovery.
Enter an X if the Declarant has no preference regarding the withdrawal or withholding of life-prolonging treatment.
The program selects this option based on a previous entry. This field can only be modified by returning to the field where the information was originally entered. This provision must be initialed by the Declarant when the Living Will is signed.
Enter an X if the Declarant desires that life-prolonging treatment be withdrawn or withheld if two physicians certify that Declarant is in a permanently unconscious condition and which condition is reasonably concluded to be irreversible (persistent vegetative state).
WND02
! Nutrition/Hydration Section (2 of 7)
2. NUTRITION/HYDRATION. Concerning the administration of nutrition and hydration, I understand that if I make no statement about nutrition or hydration, my attending physician may withhold or withdraw nutrition or hydration if the physician determines that I cannot physically assimilate nutrition or hydration or that nutrition or hydration would be physically harmful or would cause unreasonable physical pain.
a. Nutrition. I have made the following decision concerning the administration of nutrition when my death is imminent (initial the selected statement):
! _____ (Declarant's initials) I wish to receive nutrition.
! _____ (Declarant's initials) I wish to receive nutrition unless I cannot physically assimilate nutrition, nutrition would be physically harmful or would cause unreasonable physical pain, or nutrition would only prolong the process of my dying.
! _____ (Declarant's initials) I do not wish to receive nutrition.
! _____ (Declarant's initials) I make no statement concerning the administration of nutrition.
b. Hydration. I have made the following decision concerning the administration of hydration when my death is imminent (initial the selected statement):
! _____ (Declarant's initials) I wish to receive hydration.
! _____ (Declarant's initials) I wish to receive hydration unless I cannot physically assimilate hydration, hydration would be physically harmful or would cause unreasonable physical pain, or hydration would only prolong the process of my dying.
! _____ (Declarant's initials) I do not wish to receive hydration.
! _____ (Declarant's initials) I make no statement concerning the administration of hydration.
This required section describes the circumstances under which you, the Declarant, want to have life-prolonging treatment withheld or withdrawn if you become terminally ill or permanently unconscious. Press [Ctrl+F1] for more information.
Enter an X if the Declarant wishes to receive artificially administered NUTRITION even if the Declarant's death is imminent. This provision must be initialed by the Declarant when the Living Will is signed. Press [Ctrl+F1] for more information.
Enter an X if the Declarant does NOT wish to receive artificially administered NUTRITION if it cannot be physically assimilated, would be physically harmful, would cause unreasonable physical pain, or would only prolong the process of dying. This provision must be initialed by the Declarant when the document is signed.
Enter an X if the Declarant does NOT wish to receive artificially administered NUTRITION if the Declarant's death is imminent. This provision must be initialed by the Declarant when the Living Will is signed.
Enter an X if the Declarant has no preference regarding the provision, withdrawal or withholding of artificially administered NUTRITION. This provision must be initialed by the Declarant when the Living Will is signed.
Enter an X if the Declarant wishes to receive artificially administered HYDRATION (fluids) even if the Declarant's death is imminent. This provision must be initialed by the Declarant when the Living Will is signed. Press [Ctrl+F1] for more information.
Enter an X if the Declarant does NOT wish to receive artificially administered HYDRATION (fluids) if it cannot be physically assimilated, would be harmful or cause unreasonable physical pain, or would only prolong the process of dying. This provision must be initialed by the Declarant when the Living Will is signed.
Enter an X if the Declarant does NOT wish to receive artificially administered HYDRATION (fluids) if the Declarant's death is imminent. This provision must be initialed by the Declarant when the Living Will is signed.
Enter an X if the Declarant has no preference regarding the provision, withdrawal or withholding of artificially administered HYDRATION (fluids). This provision must be initialed by the Declarant when the Living Will is signed.
WND03
! Optional Pregnancy Section (3 of 7)
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 treatment, it is my preference that this document be given effect at that
point.
! [Optional additional sentence] If life-prolonging treatment 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-prolonging treatment.
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 treatment should be withheld or withdrawn.
LAL05
! Optional Other Specific Requests Section (4 of 7)
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 (5 of 7)
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.
WND06
! Declarant Signature Section (6 of 7)
I understand the importance of this declaration, I am voluntarily signing this declaration, I am at least eighteen years of age, and I am emotionally and mentally competent to make this declaration.
I understand that I may revoke this declaration at any time.
________________________________________
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 name or edit the information as desired. Use the P.I. Manager to select and paste a record.
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 Declarant's country, 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.
WND07
! Witness Signature Section (7 of 7)
[CAREFULLY REVIEW THE RESTRICTIONS ON WHO MAY BE A WITNESS. IF THE DOCUMENT IS NOT PROPERLY WITNESSED, IT MAY NOT BE ENFORCEABLE.]
[NOTE: If the declarant is a resident of a long-term care facility at the time the declaration is made, one of the two witnesses to the declaration must be:
1. A recognized member of the clergy,
2. An attorney licensed to practice in this state,
3. A person designated by the department of human services, or the County court for the county in which the facility is located.]
The Declarant has been personally known to me and I believe the Declarant to be of sound mind. I am not related to the Declarant by blood or marriage, nor would I be entitled to any portion of the Declarant's estate upon the Declarant's death. I am not the Declarant's attending physician, a person who has a claim against any portion of the Declarant's estate upon the Declarant's death, or a person directly financially responsible for the Declarant's medical care.
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.
(.txt)