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This required section states the circumstances under which life-sustaining procedures or treatment will be withheld or withdrawn. 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section in which the Declarant states whether artificially administered nutrition and hydration should be withheld or withdrawn.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optional section lists the names of two people who should be notified, if it is determined that life support should be withdrawn or withheld from the Declarant. 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 and a Notary Public. Press [Ctrl+F1] for more information.
This required section provides signature lines for the witnesses and a Notary Public. Press [Ctrl+F1] for more information.
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Living Will
LIW_OH
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declares his/her intention that withholding or withdrawal of life-sustaining procedures should be withheld or withdrawn under certain circumstances.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.
WOH01
! Declaration Section (1 of 10)
LIVING WILL DECLARATION
Declaration made this _____ day of _______________, 19___.
I, !, being of sound mind, and not under or subject to duress, willfully and voluntarily make known my desires regarding the use or continuation, or the withholding or withdrawal, of life-sustaining treatment. If I am unable to give directions regarding the use of such life-sustaining treatment when I am in a terminal condition or a permanently unconscious state, it is my intention that this declaration shall be honored by my family and physicians as the final expression of my right to refuse medical or surgical treatment, including life-sustaining treatment. I am emotionally and mentally competent to make this declaration, and I understand and accept the consequences of such refusal.
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.
WOH02
! Life Support Section (2 of 10)
If at any time I am in a "terminal condition", I direct that life-sustaining treatment that serves principally to prolong the process of dying shall be withheld or withdrawn by my attending physician, and that I be permitted to die naturally with only the administration of treatment deemed necessary to provide me with comfort care. THE TERM "TERMINAL CONDITION" MEANS AN IRREVERSIBLE, INCURABLE, AND UNTREATABLE CONDITION CAUSED BY DISEASE, ILLNESS OR INJURY FROM WHICH, TO A REASONABLE DEGREE OF MEDICAL CERTAINTY AS DETERMINED IN ACCORDANCE WITH REASONABLE MEDICAL STANDARDS BY MY ATTENDING PHYSICIAN AND ONE OTHER PHYSICIAN WHO HAS EXAMINED ME, BOTH OF THE FOLLOWING APPLY: (i) THERE CAN BE NO RECOVERY, (ii) AND DEATH IS LIKELY TO OCCUR WITHIN A RELATIVELY SHORT TIME IF LIFE-SUSTAINING TREATMENT IS NOT ADMINISTERED.
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.
WOH03
! Optional Coma Section (3 of 10)
If at any time I should be in a "permanently unconscious state", I direct that life-sustaining treatment that serves principally to prolong the process of dying shall be withheld or withdrawn by my attending physician, and that I be permitted to die naturally with only the administration of treatment deemed necessary to provide me with comfort care. THE TERM "PERMANENTLY UNCONSCIOUS STATE" MEANS A STATE OF PERMANENT UNCONSCIOUSNESS THAT, TO A REASONABLE DEGREE OF MEDICAL CERTAINTY AS DETERMINED IN ACCORDANCE WITH REASONABLE MEDICAL STANDARDS BY MY ATTENDING PHYSICIAN AND ONE OTHER PHYSICIAN WHO HAS EXAMINED ME, IS CHARACTERIZED BY THE FOLLOWING: (i) I AM IRREVERSIBLY UNAWARE OF MYSELF AND MY ENVIRONMENT, AND (ii) I HAVE A TOTAL LOSS OF CEREBRAL CORTICAL FUNCTIONING, RESULTING IN MY HAVING NO CAPACITY TO EXPERIENCE PAIN OR SUFFERING.
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.
WOH04
! Optional Nutrition Section (4 of 10)
IT IS MY INTENT THAT ARTIFICIALLY OR TECHNOLOGICALLY ADMINISTERED HYDRATION AND NUTRITION SHALL BE WITHHELD OR WITHDRAWN BY MY ATTENDING PHYSICIAN, IF I AM IN A PERMANENTLY UNCONSCIOUS STATE AND IF MY ATTENDING PHYSICIAN AND AT LEAST ONE OTHER PHYSICIAN WHO HAS EXAMINED ME, DETERMINE TO A REASONABLE DEGREE OF MEDICAL CERTAINTY AND IN ACCORDANCE WITH REASONABLE MEDICAL STANDARDS, THAT SUCH NUTRITION OR HYDRATION WILL NOT, OR NO LONGER WILL, SERVE TO PROVIDE COMFORT TO ME OR TO ALLEVIATE PAIN. As a further indication that the above authorization regarding nutrition and hydration is my intent, I am signing the following signature line.
________________________________________
Signature authorizing withdrawal of
artificially administered nutrition and
hydration
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 permanently unconscious. Ohio law does not authorize the withdrawal of artificial nutrition and hydration if you are terminally ill. Press [Ctrl+F1] for more information.
WOH05
! Optional Notification Section (5 of 10)
If my attending physician determines that life-sustaining treatment should be withheld or withdrawn, I ask that my physician make a reasonable effort to notify one of the following designated persons with the priority as listed below:
Name: !
Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
Country: !
Phone: Home: ! Work: !
Relation, if any: !
Name: !
Address:Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
Country: !
Phone: Home: ! Work: !
Relation, if any: !
Enter an X to include a section which lists the names of two people to be notified if it is determined that life-sustaining treatment should be withheld or withdrawn from the Declarant.
Enter the name of the first person to be contacted or use the P.I. Manager to select and paste a record.
Enter the street address of the first person to be contacted or edit the information as desired.
Enter the extended street address of the first person to be contacted or edit the information as desired.
Enter the city of the first person to be contacted or edit the information as desired.
Enter the state/province of the first person to be contacted or edit the information as desired.
Enter the zip/postal code of the first person to be contacted or edit the information as desired.
Enter an X to include the country in which the first person to be contacted resides, if outside the United States.
Enter the country or edit the information as desired.
Enter the home phone number of the first person to be contacted or edit the information as desired.
Enter the work phone number of the first person to be contacted or edit the information as desired.
Enter a term that best describes the relationship.
Enter the name of the second person to be contacted or use the P.I. Manager to select and paste a record.
Enter the street address of the second person to be contacted or edit the information as desired.
Enter the extended street address of the second person to be contacted or edit the information as desired.
Enter the city of the second person to be contacted or edit the information as desired.
Enter the state/province of the second person to be contacted or edit the information as desired.
Enter the zip/postal code of the second person to be contacted or edit the information as desired.
Enter an X to include the country in which the second person to be contacted resides, if outside the United States.
Enter the home phone number of the second person to be contacted or edit the information as desired.
Enter the work phone number of the second person to be contacted or edit the information as desired.
LAL04
! Optional Pregnancy Section (6 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 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 (7 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 (8 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.
WOH09
! Declarant Signature Section (9 of 10)
I understand the purpose and effect of this Living Will Declaration and sign my name after careful deliberation on _______________ _____, 19___, at !, Ohio.
________________________________________
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 name of the city in which this document will be signed or edit the information as desired.
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.
WOH10
! Witness/Notary Section (10 of 10)
Note: This document may be properly signed by having the Declarant's signature acknowledged in the presence of either (i) two qualified witnesses, or (ii) a notary public.
[Choose either the "Witness Block" or the "Notary Block" which follows.]
! WITNESS BLOCK
The undersigned witnesses attest that the Declarant signed or acknowledged this declaration in our presence. We further attest that we are adults who are not related to the Declarant by blood, marriage, or adoption, are not the attending physician of the Declarant, and are not the administrator of any nursing home in which the Declarant is receiving care. It is the belief of each of the undersigned witnesses that the Declarant appears to be of sound mind and not under or subject to duress, fraud, or undue influence.
STATE OF OHIO, COUNTY OF _________________________, SS:
On this the _____ day of _______________, 19___, before me, the undersigned Notary Public, personally appeared !, known to me or satisfactorily proven to be the person whose name is subscribed to the above Living Will Declaration as the Declarant, and acknowledged that (s)he executed the same for the purposes expressed in the document. I attest that the Declarant appears to be of sound mind and not under or subject to duress, fraud or undue influence.
________________________________________
Notary Public
This is a required section in which witnesses or a Notary Public acknowledge that the Declarant signed this document.
Enter an X if two witnesses will be signing this document to acknowledge that the Declarant signed this document. 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 first witness' street address or edit the information as desired.
Enter the first witness' extended street address or edit the information as desired.
Enter the first witness' city or edit the information as desired.
Enter the first witness' state/province or edit the information as desired.
Enter the first witness' zip/postal code or edit the information as desired.
Enter an X to include the country in which the first witness resides, 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 the second witness' street address or edit the information as desired.
Enter the second witness' extended street address or edit the information as desired.
Enter the second witness' city or edit the information as desired.
Enter the second witness' state/province or edit the information as desired.
Enter the second witness' zip/postal code or edit the information as desired.
Enter an X to include the country in which the second witness resides, if outside the United States.
Enter an X if a Notary Public will sign this document to acknowledge that the Declarant signed this document. Press [Ctrl+F1] for more information.
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