Updated for 2016: Any competent adult may sign a declaration, known as a living will in which he or she directs the withholding or withdrawal of medical care to oneself, effective upon the on loss of competency. The requirements for a living will within the state of Tennessee are described in Tenn. Code Ann. § 32-11-101 et seq., known as the "Tennessee Right to Natural Death Act." These provisions establish the following requirements:

(1) The declaration must be in writing and signed by the principal.
(2) The declaration is valid if the principal's signature is either attested by a notary public with no witnesses or witnessed by two (2) witnesses without attestation by a notary public.
(3) The witness must meet certain requirements. A valid witness under Tennessee law is defined as a competent adult, who is not the agent. At least one witness must not be related to the principal by blood, marriage, or adoption and must not be entitled to any portion of the principal's estate under any will, codicil, or under the laws of intestacy. The declaration must contain an attestation clause affirming the witnesses' compliance with these requirements.

After completing the living will, the declarant (or someone acting on the declarant's behalf) should deliver a copy of the living will to the attending physician and/or any other relevant health care providers. Upon receipt, the attending physician is required to make the living will declaration a part of the patient's medical record.

The form shown below is fully compliant with all requirements under Tennessee law.


TENNESSEE STATUTORY LIVING WILL

I, _________________________________, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, and do hereby declare:

If at any time I should have a terminal condition and my attending physician has determined there is no reasonable medical expectation of recovery and which, as a medical probability, will result in my death, regardless of the use or discontinuance of medical treatment implemented for the purpose of sustaining life, or the life process, I direct that medical care be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medications or the performance of any medical procedure deemed necessary to provide me with comfortable care or to alleviate pain.


ARTIFICIALLY PROVIDED NOURISHMENT AND FLUIDS:

By checking the appropriate line below, I specifically:

______   Authorize the withholding or withdrawal of artificially provided food, water or other nourishment or fluids.

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


ORGAN DONOR CERTIFICATION:

Notwithstanding my previous declaration relative to the withholding or withdrawal of life-prolonging procedures, if as indicated below I have expressed my desire to donate my organs and/or tissues for transplantation, or any of them as specifically designated herein, I do direct my attending physician, if I have been determined dead according to Tennessee Code Annotated, § 68-3-501(b), to maintain me on artificial support systems only for the period of time required to maintain the viability of and to remove such organs and/or tissues.

By checking the appropriate line below, I specifically:

______   Desire to donate my organs and/or tissues for transplantation.

______   Desire to donate my _____________________________________________. (Insert specific organs and/or tissues for transplantation)

______   DO NOT desire to donate my organs or tissues for transplantation.

In the absence of my ability to give directions regarding my medical care, it is my intention that this declaration shall be honored by my family and physician as the final expression of my legal right to refuse medical care and accept the consequences of such refusal.

The definitions of terms used herein shall be as set forth in the Tennessee Right to Natural Death Act, Tennessee Code Annotated, § 32-11-103.

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

In acknowledgment whereof, I do hereinafter affix my signature on this the ______ day of ______________, 20____.


__________________________________
Signature of Declarant


We, the subscribing witnesses hereto, are personally acquainted with and subscribe our names hereto at the request of the declarant, an adult, whom we believe to be of sound mind, fully aware of the action taken herein and its possible consequence.

We, the undersigned witnesses, further declare that we are not related to the declarant by blood or marriage; that we are not entitled to any portion of the estate of the declarant upon the declarant's decease under any will or codicil thereto presently existing or by operation of law then existing; that we are not the attending physician, an employee of the attending physician or a health facility in which the declarant is a patient; and that we are not persons who, at the present time, have a claim against any portion of the estate of the declarant upon the declarant's death.



______________________________________
Witness



______________________________________
Witness



STATE OF TENNESSEE
COUNTY OF __________________

Subscribed, sworn to and acknowledged before me by ____________, the declarant, and subscribed and sworn to before me by ________ and ________, witnesses, this ______ day of ____________, 20____.



_______________________________________
Notary Public

My Commission Expires: __________________________