Living Will made this ____day of______________, 20_______.
I, _______________________________, being of sound mind, willfully and voluntarily make known my desire that my life shall not be prolonged under the circumstances set forth below and do declare:
1. Withdrawing and withholding of life sustaining procedures. If, at any time, I should (place initials next to each desired option):
______ have a terminal condition
______ become comatose with no reasonable expectation of regaining consciousness; and/or
______ become in a persistent vegetative state with no reasonable expectation of regaining significant cognitive function,
I direct that the application of life-sustaining procedures to my body (place initials next to each desired option):
______ Hydration; and/or
be withheld or withdrawn and that I be permitted to die.
2. Directions to family and physicians: In the absence of my ability to give directions regarding the use of such life sustaining procedures, it is my intention that this Living Will be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment. I accept the consequences from such refusal.
3. I understand that I may revoke this living will at any time.
4. I understand the full import of this Living Will. I am at least 18 years of age and am emotionally and mentally competent to make this Living Will; and
5. Pregnancy: If I am a female and I have been diagnosed as pregnant, this Living Will shall have no force and effect unless the fetus is not viable and I indicate by my initialing after this sentence that I want this Living Will to be carried out despite such pregnancy________.
__________________ ______________ _________________
City County State of residency
I hereby witness this Living Will and attest that:
(1) The declarant is personally known to me and I believe the declarant to be at least 18 years of age and of sound mind;
(2) I am at least 18 years of age;
(3) To the best of my knowledge, at the time of the execution of this Living Will, I:
(a) Am not related to the declarant by blood or marriage;
(b) Would not be entitled to any portion of the declarant ’s estate by any will or by operation of law under the rules of decent and distribution of this state;
(c) Am not the attending physician of declarant or an employee of the attending physician or an employee of the hospital or skilled nursing facility in which declarant is a patient;
(d) Am not directly financially responsible for the declarant ’s medical care; and
(e) Have no present claim against any portion of the estate of the declarant.
(4) Declarant has signed this document in my presence as above instructed, on the date above first shown.
First witness’ printed name and signature: ________________________________________
Second witness’ printed name and signature: _____________________________________
Additional witness1 is required when Living Will is signed in a hospital or skilled nursing facility.
I hereby witness this Living Will and attest that I believe the declarant to be of sound mind and to have made this Living Will willingly and voluntarily.
Witness’ printed name and signature: ___________________________________________
1Medical director of skilled nursing facility or attending physician not participating in care of the patient or chief of the hospital medical staff or staff physician or hospital designee not participating in care of the patient.
This is a MILITARY ADVANCE MEDICAL DIRECTIVE prepared pursuant to Title 10, United States Code, Section 1044c. It was prepared by an attorney who was authorized to provide legal assistance for an individual who was eligible to receive legal assistance. Federal law exempts this advance medical directive from any requirement of form, substance, formality, or recording that is provided for advance medical directives under the laws of a state. Federal law specifies that this advance medical directive shall be given the same legal effect as an advance medical directive prepared and executed in accordance with laws of the state concerned.
Life sustaining procedures - any medical procedure or intervention which, when applied to a patient with a terminal condition or in a coma or persistent vegetative state with no reasonable expectation of regaining consciousness or significant cognitive function would serve only to prolong the dying process and where, in the judgement of the attending physician and a second physician, death will occur without such procedures or interventions. The term, “life sustaining procedures” may include, at the option of the declarant, the provision of nourishment and hydration, but shall not include the administration of medication to alleviate pain or the performance of any medical procedure deemed necessary to alleviate pain.
Coma - a profound state of unconsciousness caused by disease, injury, poison, or other means and for which it has been determined that there exists no reasonable expectation of regaining consciousness. The procedure for establishing a coma is as follows: two physicians, one of whom must be the attending physician, who, after personally examining the declarant, shall certify in writing, based upon conditions found during the course of their examination, that:
a. The declarant has been in a profound state of unconsciousness for a period of time sufficient for the declarant’s physicians to conclude that the unconscious state will continue; and
b. There exists no reasonable expectation that the declarant will regain consciousness.
Persistent vegetative state - a state of severe mental impairment in which only involuntary bodily functions are present and for which there exists no reasonable expectation of regaining significant cognitive function. The procedure for establishing a persistent vegetative state is as follows: two physicians, one of whom must be the attending physician, who, after personally examining the declarant, shall certify in writing, based upon conditions found during the course of their examination, that:
a. The declarant’s cognitive function has been substantially impaired; and
b. There exists no reasonable expectation that the declarant will regain significant cognitive function.
Terminal condition - an incurable condition caused by disease, illness, or injury which, regardless of the application of life sustaining procedures, would produce death. The procedure for establishing a terminal condition is as follows: two physicians, one of whom must be the attending physician, who, after personally examining the declarant, shall certify in writing, based upon conditions found during the course of their examination, that:
a. There is no reasonable expectation for improvement in the condition of the declarant; and
b. Death of the declarant from these conditions will occur as a result of such disease, illness, or injury.
1. Ensuring your Living Will is honored: Your family, physicians, and hospitals cannot apply the terms of your Living Will unless it can be located and read. Many patients choose to place a copy in their medical records when they are admitted to a hospital. If you choose to do so, remember that it will remain in your medical record after you are discharged and will be relied upon and applied by physicians and hospitals if you are readmitted later. If you are not certain you want this to happen, remember to remove your Living Will from your medical record when you are discharged from the hospital.
2. Revocation: Your Living Will remains in effect unless you revoke it. The most effective way of revoking your Living Will is to destroy it and any copies you made. Be sure to tell your family and physicians that you have done so.
3. Competency: I understand the full import of this Living Will. I am at least 18 years of age and am emotionally and mentally competent to make this Living Will.