How To Create A Living Will Template

Updated April 10, 2022

A living will, or health care directive, allows a person (principal) to enter their end-of-life treatment preferences. The primary purpose of a living will is used to direct medical staff whether to maintain or remove life-sustaining procedures. This only comes into question if the principal is accounted to accept a last condition.

Signing Requirements – Must be signed in accordance with State police.

By State

Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
N Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
Due west Virginia
Wisconsin
Wyoming

Tabular array of Contents

Living Will Forms: By Land
What is a Living Will?
- Summary (Video)
Statutory Forms
How to Make a Living Volition (4 steps)
- Step i – Decide Treatment Options
- Stride two – Choose End-of-Life Decisions
- Pace iii – Select a Wellness Cafe Agent
- Footstep four – Signing Requirements
Sample – Living Will
How to Write

What is a Living Will?

A living will is a declaration that instructs medical staff on how to treat a person ("declarant") in a terminal condition. The document volition include whether the declarant accepts or rejects life-sustaining procedures.

Summary (Video)

Statutory Forms

How to Make a Living Will (4 steps)

Step ane – Decide Treatment Options
Stride two – Choose End-of-Life Decisions
Step three – Select a Wellness Cafe Agent
Pace 4 – Signing Requirements

Step 1 – Decide Treatment Options

Have a moment to reflect on what course of action you would similar to have in the consequence of certain medical events that could occur such as:

Alzheimer's Disease;
Dementia;
Vegetative State;
Coma; and
Incapacitation.

Depending on your private preference would you like to take the medical staff do everything possible to keep you lot live? Or, would you rather die peacefully if you cannot breathe or eat on your own?

These are questions that should be discussed betwixt you lot and your family so that in the unfortunate effect this should happen you lot and your family volition be gear up. After careful discussion, the final decisions y'all make should be reflected in the document.

Step 2 – Choose End-of-Life Decisions

If there are any other decisions besides medical intendance that y'all would like such as a priest or religious person proverb your last rights or specific funeral plans you would similar to brand information technology is best to accept written to exist carried out by your family unit.

Pace 3 – Select a Health Care Amanuensis (Optional)

Near living wills have the option of adding a health care agent to carry out the patient's intended wishes. This is helpful in the event that there is a gray area where maybe the agent selected feels there is a good take a chance for survival and volition opt against a determination made in the living will. Otherwise, the Principal tin can choose to neglect this portion of the document and have doctors and medical staff specifically attach to what is written in the living will.

Step iv – Signing the Class

The declarant will be required to sign the directive in accordance with the laws in the State. This almost commonly involves two (two) witnesses or a notary public (or both).

How to Write

Download: Adobe PDF, MS Discussion (.docx), or OpenDocument (.odt).

(1) Documentation Date. Attending Physicians and Medical Professionals charged with your care will require the most recent declaration you take made regarding your handling preferences. One time you have completed this issue, return to the first argument then record the twenty-four hour period you have signed this document.

(two) Declarant Name. Several topics of word in this directive can have a significant touch on on one's health intendance. Since this paperwork volition be referred to when a Patient is unable to communicate while enduring a serious medical condition that cannot be cured or that he or she will not recover from, it will be of import that Reviewing Physicians are positive of the Declarant issuing this directive. To identify yourself as the Declarant, you must tape your full name to the kickoff article and provide some supporting information where requested.

(3) Declarant Mailing Address.

(4) Declarant Social Security Number.

A. Life SupportUnacceptable Quality Of Life

(5) Chronic Coma Or Persistent Vegetative Country. This certificate can be utilized every bit an instrument to draw what y'all consider an intolerable quality of life to Physicians when you cannot speak or otherwise make such thoughts and beliefs known. For case, if y'all wish Physicians to know that you believe a lifelong coma or beingness in a permanent vegetative land is an unacceptable way to alive then initial the argument on this topic and identify an "x" in the corresponding checkbox. If you practise non wish to make such a argument to Physicians who may need to review this paperwork in the future, then do non marking it.

(half dozen) No Longer Able To Communicate My Needs. Some medical conditions will leave you in a state where you are aware of your environs and those effectually you but lack the ability to communicate. If you wish Medical Professionals to be aware that such a outcome from whatever condition will not be considered a recovery considering you practice not believe you lot could live this way, then initial the second argument presented.

(7) No Longer Able To Recognize Family Or Friends. If your quality of life is strongly related to being able to recognize the people around you lot as family or friends then you can inform Physicians that a loss of this ability will be as well debilitating to exist labeled a recovery. To label the inability to recognize friends and family equally an intolerable quality of life, initial the third statement.

(8) Total Dependence On Others For Daily Intendance. The fourth statement of this area volition identify being totally dependent on other people for day-to-mean solar day self-intendance activities (i.e. getting dressed, bathing, brushing teeth, eating, traveling, etc) every bit being an intolerable quality of life. Initial this statement to let Physicians treating y'all in the futurity that such a state would exist considered an unacceptable level of living.

(ix) Other. If there are activities, lifestyles, or basic qualities that you cannot live without (i.e. vision or the ability to move your limbs) then utilise the area provided in the concluding argument ("Other") to discuss them. This item must be initialed and selected to be considered a valid statement.

Nourishment And Hydration

(10) Requesting Medically Delivered Nourishment And Fluids. Now that you lot take divers what you believe are unacceptable losses to your abilities to survive or maintain a comfortable and tolerable lifestyle, a discussion on how Physicians should treat yous when suffering the debilitations mentioned in the previous section must ensue. The showtime topic concerns the medical commitment of nutrients and water/fluids. If you accept an intolerable quality of life and wish to receive nutrients and h2o/fluids even though medical technology will be needed to deliver them to your system so initial the first statement made.

(11) Refusing Artificially Delivery Of Nourishment And Fluids. If you volition exist stricken with an intolerable quality of life from an untreatable medical condition, then (in many states) you will take the pick of denying medically delivered diet and water/fluids when you can no longer proceeds nourishment or hydration without the aid of medical engineering. To brand this argument, initial the 2d argument.

B. Sure Life-Sustaining Treatment

(12) Cardiopulmonary Resuscitation. The apply of cardiopulmonary resuscitation is considered standard procedure when ane's lungs and/or eye seize or get ineffective. This system delivers oxygenated claret to the brain, thus when information technology fails death tin can occur soon. If you do non wish CPR (cardiopulmonary resuscitation) practical equally a reaction to your heart and/or lungs stopping, and so initial the first statement in Section B. Make sure to mark the checkbox presented with this argument as well.

(13) Ventilation (Breathing Auto). Quite a few medical conditions will result in being unable to physically inhale or exhale. This may be from a blockage or internal trauma to the airway, lungs, and/or surrounding tissues. In many cases, Physicians can utilise medical technology to help you breathe as a response to such a condition. If you lot exercise not wish to be connected to a animate machine even if this means you volition choke then submit your initials and select the advisable checkbox to the second argument of Section B.

( fourteen) Feeding Tube. You can deny the apply of a feeding tube nether any circumstances by initialing the tertiary definite of this list.

(15) Dialysis. The 4th topic, "Dialysis," is a procedure used to support your kidneys' part by removing blood toxins that must be excreted. You can reject the awarding of dialysis regardless of how this will result your health or longevity by initialing the appropriate line and marking the corresponding checkbox.

(16) Other. Some states volition allow you to reject quite a few treatments. The above list constitutes the about common treatments that may crave consent or tin exist denied under certain circumstances by the Patient. If there are other medical procedures or medications that you wish to reject under any circumstances then list them later on the word "Other." You may as well title an zipper with this information and so present the attachment title on this line. This option must exist initialed and check marked or selected to be applied every bit your directives in this certificate.

C. Terminate Of Life Wishes

(17) Almost Death Requests. If in that location are any preferences that y'all wish considered when y'all are nearly death then use Section C to nowadays them. Hither, you may present requests for a hospice, specific care or treatment, the preference to dice at home, your memorial preferences, your religious concerns, organ donation, and any other topic that is important to you.

II. Wellness Care (Medical Power Of Chaser With Mental Health Authority

(18) Primary Proper noun. A second action tin can be taken with this directive. Yous may use it to proper name a specific (and trusted) Family Member and/or Friend to make medical decisions on your behalf when you practise non have the ability to make them yourself or when you cannot communicate your medical instructions finer. To begin this process, identify yourself as the Patient or the Principal who is issuing this designation.

(19) Medical And Mental Wellness Care Attorney-in-Fact. While, in most states, at that place are no formal requirements for your Medical or Mental Wellness Chaser-in-Fact then long as he or she is an developed, there are several basic attributes he or she must accept. Your Medical Attorney-in-Fact or Mental Health Care Attorney-in-Fact volition exist approved by you to take the reigns in consulting and determining with Physicians what the next steps of your treatment should exist. This is a useful precaution so long as the Party you designate is trustworthy, reliable, and kept informed on your medical preferences. Determine who this Person is then, so long as they agree to this responsibleness, name them as your Medical or Mental Health Intendance Attorney-in-Fact on the blank line provided in the designation statement.

(20) Phone Number And Address Of Amanuensis.

Specific Consent For Agent Actions

(21) Comprisal Power. Several decisions will be in the hands of your Medical and Mental Health Care Chaser-in-Fact. Depending on the state, this Agent can represent you in manners not just effecting your treatment, only besides your admittance to mental health intendance facilities so long as yous have given him or her the consent to practice and so. Initial the appropriate statement to give your Medical and Mental Wellness Care Attorney-in-Fact the consent and power Medical Professionals must run into to allow him or her to admit you lot to inpatient psychiatric care.

(22) Durability Of Directive And Designation. In some cases, interested Parties may seek to overturn your Amanuensis's decisions or those that y'all put along in the directive above. To prevent this and declare this as a durable effect even when you are incapacitated, the second statement must comport your initials.

(23) Successor Agent Name And Contact Information. If your Medical or Mental Health Care Attorney-in-Fact cannot fulfill this function, will not fulfill this role, or cannot be reached to do then, then Physicians may be left without direction when you are incapacitated. Past naming a Successor Amanuensis in this document, yous will be blessing a specific Party as a Back-up or Reserve Agent who may be reached and requested to human action as your Medical or Mental Health Care Attorney-in-Fact (by Physicians) should this role become vacant while y'all are incapacitated. Make this appointment by documenting the Successor Agent's complete name, address, and current telephone number to the appropriate annunciation.

Directive Execution

(24) Formal Signature Engagement. Information technology will exist considered imperative that Physicians take the latest version of your directives. Therefore, document the current date when y'all are ready to execute your signature.

(25) Principal Declarant Signature. Sign your proper noun to this announcement. The signature requirements for this document vary from state to state, thus, it is recommended that y'all sign your proper name earlier 2 Witnesses and a Notary Public.

(26) Printed Proper noun.

Signature Verification

(27) Witness 1 Signature And Proper name. You may cull to have two Witnesses verify your signature, a Notary Public authenticate your signature, or both. Regardless of a Notary Public's level of interest, if two Witnesses are present then each must read the "Witness Acknowledgment" provided. The first Witness, or Witness 1, should sign his or her name and impress information technology upon determining that the argument is accurate.

(28) Witness 1 Phone And Accost.

(29) Witness 2 Signature And Proper noun. The second Witness, or Witness two, will also need to show that the acknowledgment statement is true by signing and press his or her proper noun in the signature expanse provided.

(30) Witness ii Phone And Accost.

Notary Acknowledgment

(31) Notary Public. Since Witnesses tend to be Private Citizens, reaching them in the futurity tin exist hard. This can exist problematic in wellness care since fourth dimension can exist an issue. Thus, if possible, notarize your signature past signing this certificate before a Notary Public. He or she will give directions appropriate to the notarization process, then show proof of its completion in the "Notary Acknowledgment" section.