Living Will (Declaration of Wishes About Life-Sustaining Treatment)
I, [Your full name], born [Your date of birth], residing at [Your address], being of sound mind and at least eighteen years of age, willfully and voluntarily make this Living Will (the “Declaration”) so that my wishes about medical treatment are known and followed if I am unable to make or communicate my own decisions. I direct my family, my physicians and every health care provider caring for me to honour this Declaration as the final expression of my legal right to refuse or accept medical treatment, and I accept the consequences of that choice.
1. Definitions
In this Declaration: “Life-sustaining treatment” means any medical procedure, treatment or intervention that uses mechanical or artificial means to sustain, restore or replace a vital function and that serves only to prolong the process of dying, including mechanical ventilation, dialysis, cardiopulmonary resuscitation, antibiotics given for that purpose, and artificial nutrition and hydration. It does not include comfort care. “Terminal condition” means an incurable and irreversible condition which, in the judgment of my attending physician and one other physician, will result in my death within a relatively short time with or without life-sustaining treatment. “Permanently unconscious” means a condition, determined by my attending physician and one other physician to a reasonable degree of medical certainty, in which I have lost the capacity for thought and awareness of self and environment and will not regain it. “Comfort care” means care that relieves pain and suffering and preserves dignity, including oral food and fluids, hygiene, positioning and medication.
2. When This Declaration Applies
This Declaration applies only when (a) I am unable to make or communicate my own health care decisions, as determined by my attending physician and entered in my medical record, and (b) I am in a terminal condition or permanently unconscious as defined above. While I am able to make my own decisions, my own decisions control, whatever this Declaration says.
3. Terminal Condition
If I am in a terminal condition, my instruction about life-sustaining treatment is: [Terminal condition]. If I have chosen to have treatment withheld or withdrawn, I direct that I be permitted to die naturally with only comfort care, and that no treatment be given that serves only to prolong the dying process.
4. Permanent Unconsciousness
If I am permanently unconscious, my instruction about life-sustaining treatment is: [Permanent unconsciousness]. I understand that a person in this condition may live for years with treatment and that the choice to forgo it will result in my death.
5. Artificial Nutrition and Hydration
In the conditions described in Sections 3 and 4, my instruction about nutrition and hydration supplied by feeding tube, intravenous line or other artificial means is: [Artificial nutrition and hydration]. I understand that withholding or withdrawing artificial nutrition and hydration may cause death by dehydration or malnutrition, that comfort care will be continued, and that this choice is mine to make and is not to be overridden by my family or providers.
6. Resuscitation and Ventilation
In the conditions described in Sections 3 and 4, my instruction about cardiopulmonary resuscitation and mechanical ventilation is: [CPR and mechanical ventilation]. I ask my attending physician to write any do-not-resuscitate or portable medical order needed to carry this instruction out, so that emergency responders and facility staff will honour it.
7. Comfort Care and Relief from Pain
Whatever else I have chosen, I direct that comfort care be provided at all times and that I be kept clean, warm and as free from pain as possible. My instruction about medication that may hasten my death is: [Pain relief]. I ask that I be treated with dignity, that my family be allowed to be with me, and that my spiritual and religious practices be respected.
8. Pregnancy
If I am pregnant when this Declaration would otherwise apply, my instruction is: [If you are pregnant when this applies]. I understand that the law of some states limits the effect of a living will during pregnancy regardless of this instruction.
9. Other Wishes
I add the following wishes, which are to be read together with the instructions above and control where they are more specific: [Other wishes (or “None”)]. My primary physician is [Primary physician: name], telephone [Primary physician: phone], and I ask that this Declaration be placed in my medical record.
10. Effect; Providers Who Object
I intend this Declaration to be legally binding on my family, my physicians and every facility where I receive care, and I release any provider who follows it in good faith from liability to me or my estate. A physician or facility unwilling to comply with this Declaration for reasons of conscience shall promptly inform my family and arrange my transfer to a physician or facility that will comply, and shall continue comfort care in the meantime.
11. Revocation; Prior Declarations
I may revoke this Declaration at any time and in any manner by which I am able to communicate my intent, including by a signed writing, by telling my attending physician, or by signing a new declaration. Revocation is effective when communicated to my attending physician. This Declaration revokes any earlier living will or statement of end-of-life wishes I have made to the extent it is inconsistent with this one. It does not revoke any designation of a health care agent in a separate document; an agent so designated shall follow this Declaration.
12. Copies; Governing Law; Severability
A photocopy, scan or electronically signed copy of this Declaration has the same effect as the original. This Declaration is made under the laws of the State of [Governing law (state)], and I intend it to be honoured in any state as a declaration validly executed under that state’s law or under the law of my domicile. If any provision is held invalid, the remaining provisions shall be given full effect. This Declaration may be signed electronically, and the electronic execution record kept by the signing platform is evidence of execution; where my state requires wet-ink signatures or a notarial acknowledgment, I intend to complete those formalities on a printed copy, and that copy shall be my Declaration.
13. Signature and Attestation of Witnesses
13.1 Signature. I sign this Declaration on the date shown in the execution record, having read it and understood it, freely and without duress or undue influence.
13.2 Witnesses. Each witness, by signing below, declares that: (1) the declarant is personally known to me or proved their identity to me by satisfactory evidence; (2) the declarant signed or acknowledged this Declaration in my presence and appeared to be of sound mind and under no duress, fraud or undue influence; (3) I am at least eighteen years of age; (4) I am not related to the declarant by blood, marriage or adoption; (5) I am not entitled to any part of the declarant’s estate under a will now existing or by operation of law, and have no claim against the estate; (6) I am not the declarant’s attending physician or an employee of the attending physician, and I am not an employee, operator or patient of a health care facility where the declarant is a patient; and (7) I signed in the presence of the declarant.
First witness: [First witness: name], of [First witness: address]. Second witness: [Second witness: name], of [Second witness: address].
Signatures
Declarant (the person making this living will) · First witness · Second witness