LIVING WILL / ADVANCE HEALTHCARE DIRECTIVE
THIS LIVING WILL / ADVANCE HEALTHCARE DIRECTIVE (“Directive”) is made on [Date], by:
Name: [Full Name of Declarant]
Address: [Address of Declarant]
Date of Birth: [Date of Birth]
(Hereinafter referred to as the “Declarant”)
BACKGROUND
WHEREAS, the Declarant is of sound mind and wishes to make known their preferences regarding medical treatment in circumstances where they are unable to communicate these wishes;
NOW, THEREFORE, the Declarant makes this Directive as follows:
1. DEFINITIONS
1.1 “Healthcare Provider” means any doctor, nurse, hospital, or other person or institution involved in the medical care of the Declarant.
1.2 “Life-Sustaining Treatment” means any medical procedure or intervention that, when administered to a patient in a terminal condition or a state of permanent unconsciousness, will serve only to prolong the dying process.
2. STATEMENT OF INTENT
2.1 This Directive is intended to inform family, friends, and healthcare providers of the Declarant’s wishes regarding medical care if the Declarant becomes unable to make or communicate decisions.
3. DIRECTIONS REGARDING MEDICAL TREATMENT
3.1 End-of-Life Decisions
If at any time the Declarant should have an incurable and irreversible condition that will result in death within a relatively short time, or if the Declarant is in a persistent vegetative state or other condition of permanent unconsciousness, the Declarant directs that:
- Life-sustaining treatment shall NOT be administered or continued.
- Life-sustaining treatment shall be administered or continued.
(Choose one by marking the appropriate box.)
3.2 Artificial Nutrition and Hydration
If the Declarant is unable to eat or drink, the Declarant directs that:
- Artificial nutrition and hydration (feeding tubes, IV fluids) shall NOT be provided.
- Artificial nutrition and hydration shall be provided.
(Choose one by marking the appropriate box.)
3.3 Pain Relief and Comfort Care
The Declarant requests that medication or other measures be given as needed to alleviate pain or provide comfort, even if such measures may hasten death.
4. APPOINTMENT OF HEALTHCARE AGENT (OPTIONAL)
4.1 The Declarant hereby appoints:
Name of Agent: [Agent’s Full Name]
Address: [Agent’s Address]
Phone Number: [Agent’s Phone Number]
as their Healthcare Agent to make healthcare decisions on the Declarant’s behalf if the Declarant is unable to do so.
4.2 If the above-named Agent is unable or unwilling to act, the Declarant appoints:
Alternate Agent: [Alternate Agent’s Full Name]
Address: [Alternate Agent’s Address]
Phone Number: [Alternate Agent’s Phone Number]
5. GENERAL PROVISIONS
5.1 Revocation
This Directive may be revoked at any time by the Declarant, orally or in writing.
5.2 Copies
A copy of this Directive shall have the same effect as the original.
5.3 Governing Law
This Directive shall be governed by the laws of [Governing Law State/Country].
6. SIGNATURE
I, [Full Name of Declarant], being of sound mind, voluntarily sign this Living Will / Advance Healthcare Directive, and direct that it be honored by my family, healthcare providers, and all others as a true expression of my wishes.
Signed: ____________________________
Date: [Date]
7. WITNESS ATTESTATION
We, the undersigned witnesses, declare that the Declarant is personally known to us, appears to be of sound mind, and signed this Directive in our presence.
Witness 1:
Name: [Witness 1 Name]
Address: [Witness 1 Address]
Signature: ____________________________
Date: [Date]
Witness 2:
Name: [Witness 2 Name]
Address: [Witness 2 Address]
Signature: ____________________________
Date: [Date]
(If notarization is required in your jurisdiction, add the following section:)
8. NOTARY ACKNOWLEDGMENT (OPTIONAL)
State of [State]
County of [County]
On this [Date], before me, [Notary Name], a Notary Public, personally appeared [Declarant Name], who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this instrument, and acknowledged that they executed it.
Notary Public:
Signature: ____________________________
My Commission Expires: [Date]
Disclaimer
This document is a template and may not be suitable for all situations. The parties should consult with legal counsel before signing this agreement.
