RespiteMatch.com Health Blog

LIVING WILL
This Living Will becomes effective when I am no longer able to make my health care wishes known
and/or I can no longer participate in my own decision making regarding these wishes and my attending
physician and another consulting physician determine I have:

A terminal condition, meaning a condition caused by injury or illness from which there is no reasonable
medical probability of recovery and which, without treatment, can be expected to cause death; or
An end-stage condition, meaning a condition that is caused by injury or illness which has resulted in
severe and permanent deterioration, indicated by incapacity and complete physical dependency, and
for which, to a reasonable degree of medical certainty, treatment of the irreversible condition would be
medically ineffective; or
A persistent vegetative state, meaning a permanent and irreversible condition of unconsciousness in
which there is (1) the absence of voluntary action or cognitive behavior of any kind and (2) an inability
to communicate or interact purposefully with the environment.
To my family, physician and spiritual advisor;
To any medical facility that has been entrusted with my care;
To anyone who has an interest in my health, welfare, or affairs:
I willfully and voluntarily make this my definitive statement of my desires:
If or when I am no longer able to make my health care wishes and decisions known and it has been
determined that I have (please initial below to indicate your wishes):
______ a terminal condition ______ an end stage condition ______ a persistent vegetative state
then, I give these instructions. I want (please check yes or no for each item below to indicate your wishes):
to be allowed to die without life-prolonging procedures r yes r no
to be given medication to alleviate pain and enhance comfort r yes r no
to be kept alive by ventilators or other artificial life support r yes r no
to be fed artificially (tube fed) and hydrated artificially (IV fluids) to sustain life r yes r no
Other instructions: ______________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
I understand the importance of this Living Will and I am emotionally and mentally competent to make this statement.
These directions express my legal right to preserve my privacy and to make my own decisions known. Therefore, I
direct my family, doctors and all those concerned with my care to follow these instructions.
My signature below reflects that these are my wishes on this date _______/ _______/ 20______.
_________________________________ ________________________________
signature print name
• Witnesses must be adults 18 years old or older who are not named as people who make health care decisions
(health care surrogate) for the person making this Living Will.
• One witness must not be either the spouse or an immediate family member of the person making this Living Will.
My witness signature below reflects that this Living Will was knowingly and voluntarily signed in my presence.
________________________________________ ____________________________________________
witness signature witness signature
________________________________________ ____________________________________________
witness name (print) witness name (print)
________________________________________ ____________________________________________
address address
________________________________________ ____________________________________________
phone number phone number