Living Will Template
This Living Will is created in accordance with the laws of [State Name]. This document expresses my wishes regarding medical treatment in case I become unable to communicate those wishes myself.
Personal Information
- Full Name: ___________________________________________
- Date of Birth: _______________________________________
- Address: ____________________________________________
- City, State, Zip Code: ______________________________
Declaration
If I am diagnosed with a terminal illness or if I am in a persistent vegetative state and unable to communicate, I want the following:
- Do not resuscitate me (DNR) if my heart or breathing stops.
- Do not use life-sustaining treatment if I am unable to recover.
- I wish for comfort care, including pain relief and palliative care.
Additional Instructions
My specific requests regarding medical treatment are as follows:
- _________________________________________________________
- _________________________________________________________
- _________________________________________________________
Health Care Proxy
If possible, I designate the following person as my health care proxy:
- Name: ________________________________________
- Address: _____________________________________
- Phone Number: ______________________________
Signature
By signing below, I confirm that I understand this Living Will and its implications.
- Signature: _________________________________________
- Date: ___________________________________________