Living Will (Advance Directive)

Your Name (Declarant)

End-of-Life Decisions

If I am in a terminal condition or persistent vegetative state, my wishes regarding medical treatments are:

I want life-prolonging treatments (CPR, ventilators, etc.) administered.

I want artificial nutrition (feeding tubes) administered.

I want artificial hydration (IV fluids) administered.

I want medication administered for pain relief, even if it may hasten my death.

Healthcare Proxy (Optional)

Proxy Name

Proxy Phone

Additional Directives

Living Will / Advance Directive

I, [Your Name], willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below.

Medical Directives

Life-prolonging treatments: I DO NOT want them administered.
Artificial nutrition: I DO NOT want it administered.
Artificial hydration: I DO NOT want it administered.
Pain relief: I direct that treatment for alleviation of pain be provided, even if it hastens my death.

Signed this _____ day of _______________, 20___.

Signature of Declarant