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This required section states the circumstances under which life-prolonging intervention will be withheld or withdrawn. 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section in which the Declarant states whether artificially administered nutrition and hydration should be withheld or withdrawn.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 is an optional section in which the Declarant 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 in which the Declarant may state additional specific requests or instructions. 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 provides an opportunity for the Declarant to request that the provisions of this document be honored. 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/or a Notary Public. 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 in which a public official (such as a Notary Public) acknowledges the signatures of the Declarant and the witnesses. Press [Ctrl+F1] for more information.
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Living Will
LIW_WV
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declares his/her intention that withholding or withdrawal of life-sustaining procedures should be withheld or withdrawn under certain circumstances.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.
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! Declaration Section (1 of 10)
LIVING WILL
Living Will made this _____ day of _______________, 19___.
I, !, being of sound mind, willfully and voluntarily declare that in the absence of my ability to give directions regarding the use of life-prolonging intervention, it is my desire that my dying shall not be artificially prolonged under the following circumstances:
A Living Will is prepared for a "Declarant". In this required section, the Declarant states his/her intentions regarding life-prolonging intervention 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.
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! Life Support Section (2 of 10)
[Access Document Information for an explanation of life-sustaining procedures.]
If at any time I should be certified by two physicians who have personally examined me, one of whom is my attending physician, to have a terminal condition or to be in a persistent vegetative state, I direct that life-prolonging intervention that would serve solely to artificially prolong the dying process or maintain me in a persistent vegetative state, be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any other medical procedure deemed necessary to keep me comfortable and alleviate pain.
This required section describes the circumstances under which you, the Declarant, want to have life-prolonging intervention withheld or withdrawn if you become terminally ill or are in a persistent vegetative state (permanently unconscious). Press [Ctrl+F1] for more information.
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! 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 keep me comfortable and 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.
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! 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 life-prolonging intervention, it is my preference that this document be given effect at that point.
! [Optional additional sentence] If life-prolonging intervention 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 life-prolonging intervention.
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 life-prolonging intervention should be withheld or withdrawn.
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! 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.
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! 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.
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! Right of Refusal Section (7 of 10)
It is my intention that this Living Will be honored as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences resulting from such refusal.
I understand the full import of this Living Will.
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.
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! Declarant Signature Section (8 of 10)
_____________________________________________
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.
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.
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! 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.]
I did not sign the Declarant's signature above for or at the direction of the Declarant. I am at least eighteen years of age and am not related to the Declarant by blood or marriage, entitled to any portion of the estate of the Declarant according to the laws of Intestate Succession of the State of West Virginia or to the best of my knowledge under any will or codicil of Declarant, or directly financially responsible for the Declarant's medical care. I am not the Declarant's attending physician or the Declarant's Health Care Representative, Proxy or Successor Health Care Representative under a Medical Power of Attorney.
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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! Notary Section (10 of 10)
STATE OF WEST VIRGINIA, COUNTY OF _________________________, SS:
The foregoing instrument was acknowledged before me this _____ day of _______________, 19___, by the Declarant and by the two witnesses whose signatures appear above.
___________________________________________
Notary Public
My commission expires:____________
This is a required section in which a Notary Public acknowledges that the witnesses and the Declarant signed this document.
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