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This required section states the circumstances under which life-sustaining procedures or treatment will be withheld or withdrawn, and includes an optional "coma" provision. Press [Ctrl+F1] for more information.
This is a required section which provides an opportunity for the Declarant to request that the provisions of this document be honored. 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section in which the Declarant states whether artificially administered nutrition and hydration should be withheld or withdrawn.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 is 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 is a required section which reserves for the Declarant the right to give instructions that override this document. 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_UT
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declares his/her intention that withholding or withdrawal of life-sustaining procedures should be withheld or withdrawn under certain circumstances.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.
WUT01
! Declaration Section (1 of 10)
DIRECTIVE TO PHYSICIANS AND PROVIDERS
OF MEDICAL SERVICES
This directive is made this _____ day of _______________, 19___.
I, !, being of sound mind, willfully and voluntarily make known my desire that my life not be artificially prolonged by life-sustaining procedures except as I may otherwise provide in this directive.
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.
WUT02
! Life Support Section (2 of 10)
I declare that if at any time I should have an injury, disease, or illness, which is certified in writing to be a terminal condition
! [Optional COMA provision] or a persistent vegetative state
by two physicians who have personally examined me, and in the opinion of two physicians the application of life-sustaining procedures would serve only to unnaturally prolong the moment of my death and to unnaturally postpone or prolong the dying process, I direct that these procedures be withheld or withdrawn and my death be permitted to occur naturally.
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 a persistent vegetative state. Press [Ctrl+F1] for more information.
Enter an X if you want to have life-sustaining procedures or treatment withheld or withdrawn if you enter a persistent vegetative state. Press [Ctrl+F1] for more information.
WUT03
! Right of Refusal Section (3 of 10)
I expressly intend this directive to be a final expression of my legal right to refuse medical or surgical treatment and to accept the consequences from this refusal which shall remain in effect notwithstanding my future inability to give current medical directions to treating physicians and other providers of medical services.
This required section states the Declarant's request that the Living Will be followed. It also notes the Declarant's basic right to make medical decisions, including the right to refuse treatment.
WUT04
! Optional Nutrition Section (4 of 10)
I understand that the term "life-sustaining procedure" includes artificial nutrition and hydration and any other procedures that I specify below to be considered life-sustaining, but does not include the administration of medication or the performance of any medical procedure which is intended to provide comfort care or to alleviate pain.
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 provide comfort care 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 in a persistent vegetative state. 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 condition or are in a persistent vegetative state.
Enter an X if you DO NOT WISH TO RECEIVE artificially administered nutrition and hydration if your physicians certify that you have a terminal condition or are in a persistent vegetative state.
LAL04
! Optional Pregnancy Section (5 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 (6 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 (7 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.
WUT08
! Reserved Rights Section (8 of 10)
I reserve the right to give current medical directions to physicians and other providers of medical services so long as I am able, even though these directions may conflict with the above written directive that life-sustaining procedures be withheld or withdrawn.
This required section reserves for the Declarant the right to give current medical instructions, even though the instructions may be in conflict with the terms of this document. Press [Ctrl+F1] for more information.
WUT09
! Declarant Signature Section (9 of 10)
I understand the full import of this directive and declare that I am emotionally and mentally competent to make this directive.
________________________________________
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 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.
WUT10
! Witness Signature Section (10 of 10)
[CAREFULLY REVIEW THE RESTRICTIONS ON WHO MAY BE A WITNESS. IF THE DOCUMENT IS NOT PROPERLY WITNESSED, IT MAY NOT BE ENFORCEABLE.]
We witnesses certify that each of us is 18 years of age or older and each personally witnessed the Declarant sign or direct the signing of this directive; that we are acquainted with the Declarant and believe him/her to be of sound mind; that the Declarant's desires are as expressed above; that neither of us is a person who signed the above directive on behalf of the Declarant; that we are not related to the Declarant by blood or marriage nor are we entitled to any portion of the Declarant's estate according to the laws of Intestate Succession of this state or under any will or codicil of the Declarant; and we are not directly financially responsible for the Declarant's medical care; and that we are not agents of any health care facility in which the Declarant may be a patient at the time of signing this directive.
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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