New York Living Will

LIVING WILL

STATE OF NEW YORK

(Prepared to provide clear and convincing evidence of treatment wishes under New York common law — In re Westchester County Medical Center, 72 N.Y.2d 517 (1988). Not a statutory form.)

New York has no statutory living-will form. In the O’Connor case, the New York Court of Appeals recognized that life-sustaining treatment may be withheld or withdrawn when a patient’s wishes are established by clear and convincing evidence. I make this directive to state those wishes clearly if I later cannot communicate or make health-care decisions.

I, ________________________________________________________________________

being an adult of sound mind, voluntarily declare that if I become unable to participate in decisions regarding my medical care, the following directions express my settled wishes and are intended to guide my family, health-care agent (if any), physicians, and other health-care providers.

If I have an incurable or irreversible condition that will cause death within a relatively short time, I direct that treatment or procedures that serve only to prolong the dying process be withheld or withdrawn.

If I am permanently unconscious, or if I am minimally conscious because of irreversible brain damage and there is no reasonable expectation that I will recover the ability to know who I am or recognize family and friends, I direct that treatment or procedures that serve only to prolong my life be withheld or withdrawn.

In every circumstance, I direct that I receive treatment and care necessary to keep me comfortable, relieve pain and suffering, and preserve my dignity.

Specific Treatment Wishes

While I understand I am not legally required to be specific about future treatments, I feel especially strongly about the choices below. Initial each direction that you want to apply. A direction that is not initialed does not apply.

I do not want cardiac resuscitation.

I do not want mechanical respiration.

I do not want artificial nutrition and hydration.

I do not want antibiotics.

However, I do want maximum pain relief, even if it may hasten my death.

Other Directions

My additional directions, limits, or explanations are:

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

I understand that I have the legal right to refuse medical treatment. I intend this Living Will to be honored as the clearest available expression of that right and of my treatment wishes. I may revoke or change it while I have capacity.

Declaration and Signature

I sign this Living Will voluntarily and intend the directions above to control when I cannot speak for myself.

Signed: ______________________________________________________________

Date: _______________________________

Address: ______________________________________________________________

Witness Attestation (Recommended — Not Statutorily Required)

Each of us declares that the person who signed above is personally known to us or proved identity to our satisfaction; signed or acknowledged this Living Will in our presence; appeared to understand its nature; and appeared to act voluntarily and free from coercion. We sign as independent witnesses at the declarant’s request.

WITNESS 1

Signature: _____________________________________________________________

Printed name: _________________________________________________________

Address: ______________________________________________________________

Date: _______________________________

WITNESS 2

Signature: _____________________________________________________________

Printed name: _________________________________________________________

Address: ______________________________________________________________

Date: _______________________________