Living will

LIVING WILL

ADVANCE HEALTH CARE DIRECTIVE

( ${input_24_183} )

In the event that the time comes and I am incapacitated to the point that I am no longer able to actively take part in decisions for my own life, and I am unable to direct my healthcare physician as to my own medical care, I hereby authorize this Living Will as my Advance Health Care Directive to stand as a testament of my wishes.

I, ${input_24_2} , residing at , ${input_24_8_1} , ${input_24_8_3} in the County of ${input_24_8_6} in the State of ${input_24_8_4} in the zip code ${input_24_8_5} and whose telephone number is ${input_24_186} , being of sound mind, and acting willingly and without duress, fraud or undue influence, herein direct that the instructions provided herein are to be recognized as a formal statement of my desires with regards to my health care, custody and medical treatment, and as such I hereby voluntarily declare and make this designation with regards to my Living Will (aka Advance Health Care Directive and/or Health Care Proxy). These instructions and directives shall be binding upon all involved to the fullest extent allowable by law.

DESIGNATION OF HEALTH CARE ADVOCATE

I herein designate ${input_24_14} , residing at ${input_24_17_1} , ${input_24_17_3} , ${input_24_17_4} ${input_24_17_5} and whose telephone number is ${input_24_187} , as my advocate and agent to make any and all health care decisions on my behalf should I ever be diagnosed with a terminal illness, disease, injury, or should I become incapacitated or permanently unconscious (in a coma or persistent vegetative condition) where I would remain permanently unable to make decisions.

ADVOCATE’S GENERAL POWERS

My health care advocate or agent shall have the power to make health care, custody and medical treatment decisions on my behalf if my attending and/or primary physician makes the determination that I am unable to make said decisions.

I have specific directives regarding the delivery of medical care in certain health care conditions. Therefore, I wish to direct my medical treatment by way of the following conditions:

LIFE-SUSTAINING MEDICAL TREATMENT

Should any of the aforementioned events occur, I wish to leave the following directives regarding the treatment and procedures which may be used, withheld or withdrawn:

– I wish to ${input_24_62} cardiac resuscitation (CPR) in an attempt to try andprolong my life.

– I wish to ${input_24_65} life-support (e.g., respirators, ventilators) used in an effort to replace or support my natural breathing.

– I wish to ${input_24_68} tube feeding or any other artificial or invasive form of nutrition (food) or hydration (water).

– I wish to ${input_24_71} blood or blood products.

– I wish to ${input_24_74} any form of surgery or invasive diagnostic tests.

– I wish to ${input_24_77} kidney dialysis.

– I wish to ${input_24_80} antibiotics or medication in an attempt to try and prolong my life.

I understand that if I do not specifically indicate my preferences above regarding any of the forms of treatment, I may be subjected to that form of treatment.

COMFORT AND PAIN RELIEF

With regards to the aforementioned medical situations outlined above, I herein provide the following directives pertaining to the comfort care and pain relief:

– I wish to ${input_24_83} maximum pain relief medication.

– I wish to ${input_24_86} maximum pain relief medication if it may unintentionally hasten my death.

– I wish to ${input_24_89} maximum pain relief medication if it may result in temporary addiction should I survive, recover or rebound from my current conditions and/or extended hospital stay.

ADVOCATE’S OBLIGATION

My appointed advocate or agent shall make health care decisions on my behalf in accordance with my other wishes known to my advocate and/or agent. To the extent that my wishes are not known to my advocate or agent, my advocate or agent shall make the necessary health care decisions for me in accordance to what my advocate deems to be in my best interest. In determining those best interests, my advocate shall take into consideration my personal values to the extent known to the advocate.

END OF LIFE DECISIONS

I direct my health care advocate, health care provider and others who may be involved in my health care, to withhold or withdraw treatment in accordance with the choice I have indicated below:

DECLARANT STATEMENT AND SIGNATURE

This instrument shall be governed by the laws of , and I respectfully request that it be honored in any state in which I may reside at the time that this Living Will shall take effect.

By signing below, I certify that I am fully aware and completely understand the contents of this document, and that I am of sound body and mind. Furthermore, I am of the legal age of consent and not under undue influence, fraud or duress.

WITNESSES

This Living Will (aka Advance Health Care Directive and/or Health Care Proxy) must be signed by two adult witnesses that are personally present when I sign this document.

WITNESS STATEMENT

I certify that I am of 18 years of age or older and that I know the Declarant personally or have been provided with valid identification to his/her identity and believe him/her to be of sound mind and under no duress, fraud or undue influence. The Declarant has had the opportunity to read this document and has signed or acknowledged his/her signature or mark in my presence.

Under penalty of perjury I declare that I am not related to the Declarant by blood, marriage or adoption, nor am I responsible for his/her medical care or costs. Furthermore, I am not the primary or attending physician or an employee of the physician or other health care provider or current care facility for the Declarant. I also attest that I am not an employee of any life or health insurance provider, nor am I involved with the direct physical care of the Declarant. Further, I have no claim to the Declarant’s estate, and to the best of my knowledge, I am not entitled to any part of the Declarant’s estate upon his/her death with any will now in existence or by any other process of law.

(Declarant Signature)(Date)

1^stWitness:	_____________________________________ _____________________ (Witness Signature) (Date)

	${input_24_169}
Address:	${input_24_170_2}
	${input_24_170_3} , ${input_24_170_4} ${input_24_170_5}
Telephone:	${input_24_195}

2^nd Witness:	_____________________________________ _____________________ (Witness Signature) (Date)

	${input_24_174}
Address:	${input_24_175_2}
	${input_24_175_3} , ${input_24_175_4} ${input_24_175_5}
Telephone:	${input_24_196}

NOTARY PUBLIC

CERTIFICATE OF ACKNOWLEDGMENT

STATE OF	${input_24_179} )
	)
COUNTY OF	${input_24_180} )

On this date,___________________________, the Declarant, ${input_24_2} , personally appeared before me and having provided verifiable identification to be the Declarant whose name is subscribed to this instrument and acknowledged to me that s/he executed the same in his/her capacity, and that by his/her signature on the instrument, executed the instrument.

I declare that s/he appears to be of sound mind and not under or subject to duress, fraud or undue influence, that s/he acknowledges the execution the same to be his/her voluntary act and deed, and that I am not the advocate, attorney-in-fact, proxy, surrogate, or a successor of any such, as designated within this document, nor do I hold any interest in his/her estate through a Will or by any other means or process of law.

WITNESS my hand and seal.

____________________________________________________

(Notary Signature)

My Commission Expires: _______________________________

(Date)

Step 1 of 29

What is the name of the person this Living Will is being created for (the Declarant)?

Is the Declarant male or female?

What is the Declarant's address?

What is the Declarant's telephone number?

What is the name of the person you appoint as your Advocate to make health care decisions on your behalf?

What is the Advocate's address and telephone number?

Would you like to appoint an Alternate Advocate in case the first is unable or unwilling to make healthcare decisions on your behalf?

What is the name and contact information of the Alternate Advocate?

Would you like to appoint a second Alternate Advocate?

What is the name and contact information of the second Alternate Advocate?

Woud you like to include a specific date or circumstance that will commence the Advocate's authority to make health care decisions for you?

Do you have a Health Care Power of Attorney that you would like to attach to this Living Will?

Would you like to stipulate in this Living Will whether you wish to receive life-sustaining medical care if diagnosed with a terminal illness?

Would you like to stipulate in this Living Will whether you wish to receive or decline life-sustaining medical care if you fall into a permanent unconscious or vegetative state?

Would you like to stipulate in this Living Will whether you wish to receive or decline life-sustaining medical care if you fall into a marginally unconscious state but still unable to make decisions?

Would you like to stipulate in this Living Will whether you wish to receive or decline life-sustaining medical care if you are diagnosed with an untreatable condition or are in severe pain?

Do you wish to receive or not receive CPR in an attempt to prolong your life?

Do you wish to receive or not receive life support (such as respirator or ventilator) in an attempt to prolong your life?

Do you wish to receive or not receive tube feeding in an attempt to prolong your life?

Do you wish to receive or not receive blood transfusions in an attempt to prolong your life?

Do you wish to receive or not receive surgery or invasive diagnostic testing in an attempt to prolong your life?

Do you wish to receive or not receive kidney dialysis in an attempt to prolong your life?

Do you wish to receive or not receive antibiotics or medications in an attempt to prolong your life?

Do you wish to receive or not receive maximum pain relief medication?

Do you wish to receive or not receive maximum pain relief medication even if it may hasten your death?

Do you wish to receive or not receive maximum pain relief medication even if it may cause a temporary addiction should you recover or survive your condition?

Do you wish to include any additional instructions on life-sustaining treatment or comfort care?

Please select from the options below all situations when you would choose not to prolong your life.

Would you like to specify who will be the Guardian in charge of your everyday needs in case you should need one?

Would you like to appoint the Advocate in charge of your health care decisions as your Guardian?

Would you like to appoint someone else to act as your Guardian?

What is name, address and telephone number of the person you would like to appoint as your Guardian?

Would you like to include an alternate Guardian?

Would you like to include a second alternate guardian?

What is the name, address and telephone number of the second alternate Guardian?

Upon death, would you like to donate any part of your body?

Would you like to specify which organs and/or tissues you would like to donate upon death?

Do you wish to allow your donated body or donated organs and parts to be used for any purpose allowable by law?

Do you wish to allow your donated body or donated organs and tissues to be used for transplantation?

Do you wish to allow your donated body or donated organs and tissues to be used for therapy (e.g., gene therapy)?

Do you wish to allow your donated body or donated organs and tissues to be used for study or research?

Do you wish to allow your donated body or donated organs and tissues to be used for medical education?

Would you like to designate a primary health care physician?

What is the primary physician's name, address and telephone number?

Would you like to include an alternate health care physician?

What is the alternate physician name, address and telephone number?

Who is the first witness that will be present for the signing of this Living Will?

Who is the second witness that will be present for the signing of this Living Will?

What is the county and state where this Living Will will be signed and/or filed?

Which state's laws will govern this document?