This Living Will Declaration is a document indicating the wishes of a patient should they
become unable to make medical and other healthcare decisions. It will state an
individual’s choice regarding the use of life sustaining or life support procedures. This
document in its draft form contains numerous of the standard clauses commonly used in
these types of agreements but it can be customized to fit the needs of any individual
seeking to establish a living will.
LIVING WILL DECLARATION
I, ________________, being of sound mind and body, after careful consideration and
thought, freely and intentionally make this revocable declaration to state that if I should
become unable to make decisions as to life sustaining or life support procedures, then I
request that my dying shall not be delayed, prolonged, or extended artificially by medical
science or life sustaining medical procedures in accordance with my wishes as set forth in
this Living Will.
It is my intent in the execution of these instructions that they be carried out as fully as is
feasible by my physicians, family and friends, and legal representatives.
If I am unable to make decisions regarding the use of medical life sustaining or life
support systems and/or procedures, and if I have a sickness, illness, disease, injury or
condition which has been diagnosed by two (2) licensed medical doctors or physicians
who have personally examined me with either terminal or incurable certified to be
terminal illness; a condition from which there is no reasonable hope of my recovery to a
meaningful quality of life; has rendered me in a persistent vegetative state; a condition of
extreme mental deterioration; or permanently unconscious, I request that all medical life
sustaining or life support systems and procedures shall be withdrawn except as explicitly
set forth in this Living Will.
Nothing in this Living Will shall be interpreted as a prohibition of the administration of
pain relieving medications or procedures or other relevant palliative care provided even if
such treatment may shorten my life or have other adverse effects.
I am also stating the following additional instructions so that my Living Will is as clear as
possible:
1. In the event that I require artificial resuscitation i.e. CPR, I do/do not wish
artificial resuscitation to be performed. [Instruction: Clearly indicate your
choice]
2. In the event that I require an intravenous feeding tube, I do/ do not wish an
intravenous feeding tube to be utilized. [Instruction: Clearly indicate your
choice]
3. In the event that I require a life sustaining surgery, I do/ do not wish such
surgery to be performed.
4. _______________________________________________________________
________________
I certify that my family, the medical facility, and any doctors, nurses and other medical
personnel involved in my care shall have no civil or criminal liability for following the
instructions as set forth in this Living Will.
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If any provision of this Living Will is deemed unenforceable or considered invalid under
my current state of residence or state laws where I may be obtaining treatment, all other
provisions are to be deemed enforceable and valid and all terms are to be considered
severable.
I reserve the right to revoke all or part of this Living Will at any time. Such revocation
may be via oral statement witnessed by two witnesses or by writing, which is signed by a
witness and/or notary. [Instruction: Verify whether your jurisdiction permits a
revocation via oral statement]
A copy of this Living Will shall have the same force and effect as the original so long as
all appropriate signatures are present.
I have read and understand this Living Will, and I am freely and voluntarily signing it on
____________________ in the presence of witnesses.
Signed: ___________________________________
Street Address: _____________________________
County: ___________________________________
City and State: _____________________________
I certify that I am at least 18 years of age, mentally competent and not related to
Declarant by blood, marriage or adoption, nor do I stand to inherit any of Declarant’s
estate in the event of his/her demise, by any means including will, trust or prevailing
laws. I do not stand to benefit in any other way from the demise of Declarant nor am I
directly responsible for the health, medical care or general well being of Declarant. I
further certify that I witnessed Declarant review and sign this Living will of his/her own
free and voluntary will and I am not aware that Declarant has been forced under duress or
otherwise to sign this Living Will.
Witness signature: _______________________________
Print Name:____________________________________
Street Address: _____________________________
County: ___________________________________
City and State: _____________________