Living Will Declaration - Free Legal Form

NOTE: THE FORMS AVAILABLE IN THIS ARCHIVE ARE SUBJECT TO OUR TERMS OF USE AND ARE NOT A SUBSTITUTE FOR THE ADVICE OF AN ATTORNEY. LEGAL ADVICE OF ANY NATURE SHOULD BE SOUGHT FROM COMPETENT LEGAL COUNSEL IN THE RELEVANT JURISDICTION. THESE FORMS ARE PROVIDED "AS IS."

Main Menu > Legal Forms Archive

◘ Email Me This Form! Do you want a copy of this form emailed to you as a Word document? Read more.
◘ Fax Me This Form! Do you want a copy of this form faxed to you? Read more. Sixty nations serviced!

◘ Questions: Question about this form? Ask us, and we'll endeavor to post an answer as soon as possible.
◘ Quality: We're committed to quality. Have you found a legal problem with a form? Tell us, and earn $50!

Buy This Form for 9^.99 Professionally Formatted for Microsoft Word -- Click HERE!

"Living Will"
(Directive to Physicians)

Directive made this ____ day of ___________, 20____.

I, _______________________, being of sound mind, willfully, and voluntarily make known my desire that my life shall not be artificially prolonged under the circumstances set forth below, do hereby declare:

GENERAL PRESUMPTION FOR LIFE

    I direct my health care provider(s) and health care agent to make health care decisions consistent with my general desire for the use of medical treatment that would preserve my life, as well as for the use of medical treatment that can cure, improve, or reduce or prevent deterioration in, any physical or mental condition.
    Food and water are not medical treatment, but basic necessities. I direct my health care provider(s) and health care agent to provide me with food and fluids orally, intravenously, by tube, or by other means to the full extent necessary both to preserve my life and to assure me the optimal health possible.
    I direct that medication to alleviate my pain be provided, as long as the medication is not used in order to cause my death.
    I direct that the following be provided: the administration of medication, cardiopulmonary resuscitation (CPR), and the performance of all other medical procedures, techniques, and technologies. including surgery, - all to the full extent necessary to correct, reverse, or alleviate life-threatening or health-impairing conditions, or complications arising from those conditions.
    I also direct that I be provided basic nursing care and procedures to provide comfort care.
    I reject, however, any treatments that use an unborn or newborn child, or any tissue or organ of an unborn or newborn child, who has been subject to an induced abortion. This rejection does not apply to the use of tissues or organs obtained in the course of the removal of an ectopic pregnancy.
    I also reject any treatments that use an organ or tissue of another person obtained in a manner that causes, contributes to, or hastens that person's death.
    The instructions in this document are intended to be followed even if suicide is alleged to be attempted at some point after it is signed.
    I request and direct that medical treatment and care be provided to me to preserve my life without
discrimination based on my age or physical or mental disability or the "quality" of my life. I reject any action or omission that is intended to cause or hasten my death.
    I direct my health care provider(s) and health care agent to follow the above policy, even if I am judged to be incompetent.
    During the time I am incompetent, my agent, as named below, is authorized to make medical decisions on my behalf, consistent with the above policy, after consultation with my health care provider(s), utilizing the most current diagnoses and/or prognosis of my medical condition, in the following situations with the written special conditions.

WHEN MY DEATH IS IMMINENT

    A. If I have an incurable terminal illness or injury, and I will die imminently - meaning that a reasonably prudent physician, knowledgeable about the case and the treatment possibilities with respect to the medical conditions involved, would judge that I will live only a week or less even if lifesaving treatment or care is provided to me - the following may be withheld or withdrawn:
        - Any treatment that will, itself, cause me severe, intractable, and long-lasting pain but will not cure me.
        - (Other)________________________________________________________________

WHEN I AM TERMINALLY ILL

    B. Final Stage of Terminal Condition. If I have an incurable terminal illness or injury and even though death is not imminent I am in the final stage of that terminal condition - meaning that a reasonably prudent physician, knowledgeable about the case and the treatment possibilities with respect to the medical conditions involved, would judge that I will live only three months or less, even if lifesaving treatment or care is provided to me - the following may be withheld or withdrawn:
        - Medications intended to relieve pain but which seriously threaten to shorten my life.
        - (Other)________________________________________________________________

C. OTHER SPECIAL CONDITIONS:
- (Other)________________________________________________________________

IF I AM PREGNANT

    D. Special Instructions for Pregnancy. If I am pregnant, I direct my health care provider(s) and health care agent to use all lifesaving procedures for myself with none of the above special conditions applying if there is a chance that prolonging my life might allow my child to be born alive. I also direct that lifesaving procedures be used even if I am legally determined to be brain dead if there is a chance that doing so might allow my child to be born alive. Except as I specify by writing my signature in the box below, no one is authorized to consent to any procedure for me that would result in the death of my unborn child.
    If I am pregnant, and I am not in the final stage of a terminal condition as defined above. medical procedures required to prevent my death are authorized even if they may result in the death of my unborn child provided every possible effort is made to preserve both my life and the life of my unborn child.
    This directive shall have no force or effect five years from the date filled in above.
    I understand the full import of this directive and I am emotionally and mentally competent to make this directive in the City of ___________, County of _________, State of ________________.

__________________________________________
_________________________________, Declarant

Witnesses

The declarant has been personally known to me and I believe his/her to be of sound mind. I did not sign the declarant's signature above for or at the direction of the declarant. I am at least 18 years of age and am not related to the declarant by blood or marriage, nor entitled to any portion of the estate of the declarant according to the laws of intestate succession of the State of California or under any will of the declarant or codicil thereto as of the date of declarant's signature. Neither am I directly financially responsible for declarant's medical care. I am not the declarant's attending physician, an employee of the attending physician, or an employee of the health or care facility in which the declarant is a patient.

Witness (sign) _______________________________________________
(print)_______________________________________________
Address __________________________________________________

Subscribed and acknowledged, before me by___________________ __________________________, and subscribed and sworn to before the witnesses, on the _______day of ____________________, 20___.

(SEAL)

____________________________
NOTARY PUBLIC

State of ___________________

My Commission Expires: ____________________________

Copies of this instrument have been given to:

Receipt and acknowledged & date:

State-Specific Related Forms:

Living Will Forms
Medical Directive and Health Care Forms
Power of Attorney Forms
ILRG Legal Forms Archive (Main Index)

Buy This Form for $9^.99 Professionally Formatted for Microsoft Word -- Click HERE!

For only $9.99 have this form emailed to you as a Microsoft Word document.

For only 9.99 you can have this form emailed or faxed to you. We'll send you the form properly formatted and ready for your immediate use.

Attention attorneys and legal publishers: sell us your legal forms and earn up to $2,500 or more!

"Are these forms valid in my state?" At ILRG, we are committed to delivering top quality legal forms that are valid in all states. We will pay $50 to anyone who brings to our attention any form on our site that is not compliant with U.S. state law. See the terms and conditions for this offer for further information.

Attorney Referral Network:

Attention attorneys! Would you like to increase your practice's income? ILRG will soon introduce a new service that will help consumers locate and retain legal counsel in an exciting, innovative way. Qualified attorneys in the U.S. and Canada are being given an opportunity for a limited time to pre-register at no cost. Attorneys who pre-register are guaranteed free registration when our new service goes live. Gain new clients! Be a rainmaker at your firm, and sign-up today! [Learn More...]

Question about this form? Ask us, and we'll endeavor to post an answer as soon as possible.
First Name:
Last Name:
E-mail:
Question: Characters remaining:
This forum is not intended to provide legal advice, but rather information about the law. Submissions are subject to our terms and conditions of use.