Louisiana Living Will Declaration

LOUISIANA LIVING WILL DECLARATION

La. R.S. 40:1151 et seq. · Illustrative form: § 40:1151.2(C)

Declaration made this ________ day of ______________________, 20______.

I, ________________________________________________, being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances stated below, and declare:

If at any time I have an incurable injury, disease, or illness, or am in a continual profound comatose state with no reasonable chance of recovery, certified to be a terminal and irreversible condition by two physicians who have personally examined me, one of whom is my attending physician, and those physicians determine that my death will occur whether or not life-sustaining procedures are used and that those procedures would serve only to prolong artificially the dying process, I direct:

INITIAL ONE ELECTION ONLY

Withhold or withdraw all life-sustaining procedures, including nutrition and hydration, so that food and water will not be administered invasively.

Withhold or withdraw life-sustaining procedures except nutrition and hydration, so that food and water may be administered invasively.

I further direct that I be permitted to die naturally, with only medication or medical procedures considered necessary to provide comfort care.

If I cannot give directions about life-sustaining procedures, I intend this declaration to be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences of that refusal.

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

___________________________________________

Signature of Declarant

Printed name: ______________________________________

Date of birth: ______________________

Address: _____________________________________________________

City / State / ZIP: __________________________________________

Parish: ____________________________

WITNESS ATTESTATION

We declare that the declarant signed this written declaration in our presence. We are competent adults, are not related to the declarant by blood or marriage, and are not entitled to any portion of the declarant’s estate under any will or codicil or by operation of law.

___________________________________________

Signature of Witness 1

Printed name: ______________________________________

Address: _____________________________________________________

___________________________________________

Signature of Witness 2

Printed name: ______________________________________

Address: _____________________________________________________

OPTIONAL LIVING WILL REGISTRY

Louisiana law provides for filing a living will declaration with the Secretary of State under La. R.S. 40:1151 et seq. Registration is optional and does not replace proper execution of this declaration. Obtain current forms, fees, mailing instructions, and registry information directly from:

Louisiana Secretary of State · End of Life Registries Publications Division · P.O. Box 94125 · Baton Rouge, LA 70804-9125 Telephone: 225-922-0900 · Official website: sos.la.gov

The law’s form is illustrative; a declaration may, but need not, follow it exactly. Give copies of the signed declaration to your physician, family, and anyone likely to be involved in your care. This form is not legal advice.