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 optional section states that the Declarant can choose to be kept off life support systems, if the Declarant is permanently unconscious. 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section in which the Declarant states whether artificially administered nutrition and hydration should be withheld or withdrawn.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 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 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_NV
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declares his/her intention that withholding or withdrawal of life-sustaining procedures should be withheld or withdrawn under certain circumstances.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. Use the P.I. Manager to select and paste a record.
WNV01
! Declaration Section (1 of 8)
DECLARATION
[THIS DOCUMENT IS BEING PREPARED FOR !]
If I should have an incurable and irreversible condition, that, without the administration of life-sustaining treatment, will, in the opinion of my attending physician, cause my death within a relatively short time, and I am no longer able to make decisions regarding my medical treatment, I direct my attending physician to withhold or withdraw treatment that only prolongs the process of dying and is not necessary for my comfort or to alleviate pain.
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. Use the P.I. Manager to select and paste a record.
LMT02
! Optional Coma Section (2 of 8)
If I am in a permanently unconscious condition from which I have no known hope of regaining awareness and where the application of life-sustaining treatment only prolongs the process of dying, I direct my attending physician to withhold or withdraw treatment that merely prolongs the process of dying and is not necessary to my comfort or to alleviate pain.
A Living Will directs the Declarant's physician to withdraw or withhold life-sustaining procedures or treatment if the Declarant has a terminal condition. Enter an X if the Declarant also wants such procedures withdrawn or withheld if he or she is permanently unconscious. Press [Ctrl+F1] for more information.
WNV03
! Optional Nutrition Section (3 of 8)
If this statement reflects your desires, you must initial the statement on the line provided.
Withholding or withdrawal of artificial nutrition and hydration may result in death by starvation or dehydration. If I have a condition stated above, I direct my physician to
! _____ (initials) NOT WITHHOLD OR WITHDRAW artificial nutrition and hydration by way of the gastro-intestinal tract after all other treatment is withheld pursuant to this declaration.
! _____ (initials) WITHHOLD OR WITHDRAW artificial nutrition and hydration by way of the gastro-intestinal tract, except as is necessary to my comfort or to alleviate pain, after all other treatment is withheld pursuant to this declaration.
Enter an X to include a paragraph that states whether you wish to withhold or withdraw artificial nutrition and hydration if you are terminally ill or permanently unconscious. Press [Ctrl+F1] for more information.
Enter an X if you DO NOT WISH TO WITHHOLD OR WITHDRAW 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 WISH TO WITHHOLD OR WITHDRAW artificially administered nutrition and hydration if your physicians certify that you have a terminal or permanently unconscious condition.
LAL04
! Optional Pregnancy Section (4 of 8)
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.
WNV05
! Optional Proxy Section (5 of 8)
If I am no longer able to make decisions regarding my medical treatment, I appoint !,
currently residing at
!, ! !,
! Country: !,
or if he or she is not reasonably available or is unwilling to serve,
I appoint !,
currently residing at
!, ! !,
! Country: !,
to make decisions on my behalf regarding withholding or withdrawal of treatment that only prolongs the process of dying and is not necessary for my comfort or to alleviate pain, pursuant to applicable law. If the persons I have so appointed are not reasonably available or are unwilling to serve, I direct my physician to withhold or withdraw treatment that only prolongs the process of dying and is not necessary for my comfort or to alleviate pain.
Enter an X to include a "Proxy" provision that allows you to designate someone (a "Health Care Proxy") to make health care decisions for you if you are unable to do so. Press [Ctrl+F1] for more information.
Enter the Proxy's name or use the P.I. Manager to select and paste a record.
Enter the Proxy's street address or edit the information as desired.
Enter the Proxy's extended street address or edit the information as desired.
Enter the Proxy's city or edit the information as desired.
Enter the Proxy's state/province or edit the information as desired.
Enter the Proxy's zip/postal code or edit the information as desired.
Enter an X to include the country in which the Proxy resides, if outside the United States.
Enter the country or edit the information as desired.
Enter the Alternate Proxy's name or use the P.I. Manager to select and paste a record.
Enter the Alternate Proxy's street address or edit the information as desired.
Enter the Alternate Proxy's extended street address or edit the information as desired.
Enter the Alternate Proxy's city or edit the information as desired.
Enter the Alternate Proxy's state/province or edit the information as desired.
Enter the Alternate Proxy's zip/postal code or edit the information as desired.
Enter an X to include the country in which the Alternate Proxy resides, if outside the United States.
LAL06
! Optional Severability Section (6 of 8)
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.
WNV07
! Declarant Signature Section (7 of 8)
Signed this _____ day of _______________, 19___.
________________________________________
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 lines 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 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.
WNV08
! Witness Signature Section (8 of 8)
The Declarant voluntarily signed this writing in my presence.
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 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 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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