Florida Statutory Living Will

LIVING WILL
(Florida Statutes 765.303)

Declaration made this _____ day of ___________________________________, 20_____, I, ___________________________________, willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do hereby declare that, if at any time I am incapacitated and (initial as applicable)

    _____ I have a terminal condition

or _____ I have an end-stage condition

or _____ I am in a persistent vegetative state

and if my attending or treating physician and another consulting physician have determined that there is no reasonable medical probability of my recovery from such condition, I direct that life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain.

It is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences for such refusal.

In the event that I have been determined to be unable to provide express and informed consent regarding the withholding, withdrawal, or continuation of life-prolonging procedures, I wish to designate, as my surrogate to carry out the provisions of this declaration:

Name of Surrogate: ___________________________________

Address: ___________________________________

___________________________________

Zip Code: ________________

Phone: ___________________________________

E-Mail: ___________________________________


I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration.


Additional instructions (optional):

___________________________________

___________________________________

___________________________________

Name: ___________________________________

Signed: ___________________________________

Date: __________________


WITNESSES:

Witness #1:

Signature: ___________________________________

Printed Name: ___________________________________

Address: ___________________________________

Phone: ___________________________________

E-Mail: ___________________________________


Witness #2:

Signature: ___________________________________

Printed Name: ___________________________________

Address: ___________________________________

Phone: ___________________________________

E-Mail: ___________________________________