Living Will Declaration Form

Living Will Declaration of (Full Legal Name) Declaration made this ____ day of ________, 20__. I, (Declarant's Full Legal Name), being at least eighteen (18) years of age and of sound and disposing mind, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below. I further declare: If, at any time I have an incurable injury, disease or illness certified in writing to be a terminal condition by my attending physician, and my attending physician has determined that my death will occur within a short period of time, and the use of life-prolonging procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the provision of appropriate nutrition and hydration and the administration of medication and the performance of any medical procedure necessary to provide me with comfort, care, or to alleviate pain. In the absence of my ability to give directions regarding the use of life- prolonging procedures, it is my intention that this delaration be honored by my family and my physician(s) as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences of the refusal. I hereby state that I understand the full import of this declaration. ____________________________________ (Declarant's Full Legal Name) The declarant has been personally known to me, and I believe him/her to be of sound and disposing mind. I did not sign the declarant's signature above for, or at the direction of, the declarant. I am not a spouse, parent, or child of the declarant. I am not entitled to any part of the declarant's estate or directly financially responsible for the declarant's medical care. I am competent and at least eighteen (18) years of age. Dated this ____ day of ________, 20__. ____________________________________ Witness ____________________________________ Witness