Kentucky Living Will Directive

LIVING WILL DIRECTIVE

(Commonwealth of Kentucky · KRS 311.625)

My wishes regarding life-prolonging treatment and artificially provided nutrition and hydration to be

provided to me if I no longer have decisional capacity, have a terminal condition, or become

permanently unconscious have been indicated by checking and initialing the appropriate lines

below. By checking and initialing the appropriate lines, I specifically:

HEALTH CARE SURROGATE DESIGNATION

Optional. Check and initial the line below only if you want to name a health care surrogate. Provide contact

information so your surrogate can be reached.

(___) Designate the person named below as my health care surrogate(s) to make health care decisions for me in accordance with this directive when I no longer have decisional capacity.

PRIMARY SURROGATE NAME

TELEPHONE

ADDRESS

If the primary surrogate refuses or is not able to act for me, I designate the person named below as

my health care surrogate(s):

SUCCESSOR SURROGATE NAME

TELEPHONE

ADDRESS

Any prior designation is revoked.

DIRECTIVES

If I do not designate a surrogate, the following are my directions to my attending physician. If I

have designated a surrogate, my surrogate shall comply with my wishes as indicated below:

Life-prolonging treatment — check and initial only one:

(___) Direct that treatment be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical treatment deemed necessary to alleviate pain.

(___) DO NOT authorize that life-prolonging treatment be withheld or withdrawn.

Artificially provided nourishment and fluids — check and initial only one:

(___) Authorize the withholding or withdrawal of artificially provided food, water, or other artificially provided nourishment or fluids.

(___) DO NOT authorize the withholding or withdrawal of artificially provided food, water, or other artificially provided nourishment or fluids.

Surrogate determination of best interest — optional:

Alternative to the two sections above. If you check and initial this option, do not also check the life-prolonging

treatment or nourishment options.

(___) Authorize my surrogate, designated above, to withhold or withdraw artificially provided nourishment or fluids, or other treatment if the surrogate determines that withholding or withdrawing is in my best interest; but I do not mandate that withholding or withdrawing.

Organ donation — check and initial only one:

(___) Authorize the giving of all or any part of my body upon death for any purpose specified in KRS 311.1929.

(___) DO NOT authorize the giving of all or any part of my body upon death.

In the absence of my ability to give directions regarding the use of life-prolonging treatment and

artificially provided nutrition and hydration, it is my intention that this directive shall be honored by

my attending physician, my family, and any surrogate designated pursuant to this directive as the

final expression of my legal right to refuse medical or surgical treatment and I accept the

consequences of the refusal.

If I have been diagnosed as pregnant and that diagnosis is known to my attending physician, this

directive shall have no force or effect during the course of my pregnancy.

I understand the full import of this directive and I am emotionally and mentally competent to make

this directive.

Signed this

day of

, 20

SIGNATURE OF GRANTOR

Printed name:

Address:

COMPLETE EITHER THE TWO-WITNESS ALTERNATIVE OR THE NOTARY ALTERNATIVE. ONLY

ONE IS REQUIRED.

WITNESS ALTERNATIVE

In our joint presence, the grantor, who is of sound mind and eighteen (18) years of age, or older,

voluntarily dated and signed this writing or directed it to be dated and signed for the grantor.

SIGNATURE OF WITNESS 1

Printed name:

Address:

SIGNATURE OF WITNESS 2

Printed name:

Address:

OR

NOTARY ALTERNATIVE

Use this path instead of the two-witness path. Leave the witness lines blank if you use a notary.

Commonwealth of Kentucky, County of

Before me, the undersigned authority, came the grantor who is of sound mind and eighteen (18)

years of age, or older, and acknowledged that he or she voluntarily dated and signed this writing or

directed it to be signed and dated as above.

Done this

day of

, 20

SIGNATURE OF NOTARY PUBLIC OR OTHER OFFICER

Printed name:

Date commission expires:

NOTICE

Execution of this document restricts withholding and withdrawing of some medical procedures.

Consult Kentucky Revised Statutes or your attorney.

None of the following shall be a witness to or serve as a notary public or other person authorized to

administer oaths in regard to any advance directive made under KRS 311.625:

(a) A blood relative of the grantor;

(b) A beneficiary of the grantor under descent and distribution statutes of the Commonwealth;

(c) An employee of a health care facility in which the grantor is a patient, unless the employee

serves as a notary public;

(d) An attending physician of the grantor; or

(e) Any person directly financially responsible for the grantor's health care.

An employee, owner, director, or officer of a health care facility where the grantor is a resident or

patient shall not be designated or act as surrogate unless related to the grantor within the fourth

degree of consanguinity or affinity or a member of the same religious order.

A person designated as a surrogate pursuant to an advance directive may resign at any time by

giving written notice to the grantor; to the immediate successor surrogate, if any; to the attending

physician; and to any health care facility which is then waiting for the surrogate to make a health

care decision.

Revocation. Under KRS 311.627, this directive may be revoked at any time by a signed and dated

writing declaring an intention to revoke; by an oral statement of intent to revoke made by a grantor

with decisional capacity in the presence of two (2) adults, one (1) of whom is a health care

provider; or by destruction of the document by the grantor or by some person in the grantor's

presence and at the grantor's direction.