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Living Will

A Living Will is a statement in which you indicate the kind of medical care you want or do not want to receive should you become unable to make your own decisions or express your wishes.

A Living Will makes clear in writing your wishes concerning your health care if you have a terminal condition. It is called a "living" Will, because it comes into effect while the person is still alive.

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Document Selection
A Health Care Power of Attorney gives decision-making authority over certain issues to someone you choose. More Information

Would you like to include Health-Care Power of Attorney?

Yes No
A document indicating your wish to donate organs after death. More Information

Would you like to include an Organ and Tissue Donation document?

Yes No

General Information
It is recommended to add as many details as possible, in order to avoid identification issues in the future.
Full Name:
Date of Birth:
Social Security Number:
Two medical doctors are required to determine your health condition in order to execute your health directives. It is recommended that one of those will be your personal physician. Providing your physician's details will help locating him/her. However, you may elect not to use your physician.
Would you like to use your own Physician? Yes No
Would you like to include your physician's contact information? Yes No
Full Name:
Phone Number:
Phone Number (2):

Living Will Information
These conditions are decided by your doctor and another health care professional. Both decide that life-support treatment would only delay the moment of your death.
Terminal condition - Near death
(likely to die within a short period of time).
Yes No
End-stage condition
(in a coma from which not expected to wake up or recover, and have brain damage).
Yes No
Persistent vegetative state
(permanent and severe brain damage, and not expected to get better).
Yes No
Indicate your wishes about life-prolonging procedures when the application of such procedures would serve only to artificially prolong the process of dying.
Do you want Life-sustaining treatments (like CPR)? Yes No
Do you want artificial nutrition and hydration as the main treatment keeping you alive? Yes No
Would you like to be comfortable and free of pain even if it means prolonging the dying process or shortening your life? Yes No
Would you like to specify further wishes? Yes No
Use the area below to enter any other details that you would like:
(Leave blank if not needed)


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