LIVING WILL DECLARATION




This is only a basic form, you may want your living to be more specific.

NAME: __________________________________________________________________

ADDRESS: __________________________________________________________________

Death is as much a reality as birth, growth, maturity and old age - it is the one certainty of life. If the time comes when I can no longer take part in the decision for my own future, let this statement stand as an expression of my wishes and directions while I am still of sound mind.

Recognizing the impossibility of knowing what the future holds, these instructions apply if I am in a persistent vegetative state for more than ___________hours/days/weeks/months, or if I am permanently unconscious or in an incurable or irreversible mental or physical condition with no reasonable expectation of recovery, or if I am in any similar condition. Under any such circumstances, I direct my attending physician to withhold or withdraw treatment that only serves to prolong the process of my dying and that I be allowed to die and not be kept alive by medical procedures, medications, artificial means (including, but not limited to, artificial feeding, hydration, and respiration) or "heroic measures" (including resuscitation efforts). Under any such circumstances, I hereby consent to a Do Not Resuscitate Order and I further direct that treatment be limited to measures to keep me comfortable and to relieve pain, including pain that might occur by withholding or withdrawing treatment.

This statement is made after careful consideration and represents my firm and settled conviction to forego life sustaining procedures; further, is in accordance with my strong convictions and beliefs and is to serve as clear and convincing evidence thereof. Further, these directions express my legal right to refuse treatment. Therefore, I direct that those who act on the basis of this document do so free from any civil or criminal liability. I further direct that this statement be honored should any of the stated conditions occur in a state other than New York.

Unless I state otherwise, I intend these instructions to take effect immediately and remain in effect indefinitely.

Signature: _______________________________

Date: ____________, 20__

We declare that the person who signed or asked another to sign this document is personally known to me and appears to be of sound mind and acting willingly and free from duress. He or she signed (or asked another to sign for him or her) this document in our presence.

Witness:

__________________________________________________________________

Address:

__________________________________________________________________

Witness:
__________________________________________________________________

Address:
__________________________________________________________________


This a great link to Planning Your Health Care Im Advance, written by the New York State Attorney General's Office. It will explain Health Care Proxies, Living Wills and Do Not Resusitate Orders.

http://www.ag.ny.gov/sites/default/files/pdfs/publications/Planning_Your_Health_Care_in_Advance.pdf


I hope you find the same useful.

Dick

 






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Last Updated: October 1st, 2013  image


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