Free Printable Living Will-blank Form – A living will, or “health care declaration,” allows a person to choose their end-of-life medical wishes if treatment is no longer available. A living will is usually a power of attorney to appoint an agent to carry out the patient’s wishes.
My wishes for life-prolonging treatment, artificial nutrition, and hydration if I am disabled, terminally ill, or permanently unconscious are indicated by checking and starting the appropriate line below:
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I appoint [NAME OF SURROGATE] as my health care surrogate (“Surrogate”) to make health care decisions under this directive when I become incapacitated. If my Surrogate refuses or is unable to act for me, I appoint [NAME OF 2ND SURROGATE] as a second successor with the same powers.
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If I do not choose a surrogate, I have the following instructions for the attending physician. If I choose a surrogate, my surrogate must follow my wishes as indicated by checking and initializing the following lines:
☐ – [BEGINNINGS] – State that treatment should be withheld or withheld and natural death allowed only by drugs or any medical procedures deemed necessary for pain relief.
NOTE: If you want this option, do not select any of the previous options for Life-Prolonging Treatment and Nutrition and/or Fluids.
☐ – [INITIATION] – Allow the surrogate to withhold or withdraw artificially administered food or fluids, or perform other or other procedures, as described on the previous page; but I do not order it to be kept or taken away.
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I certify that I am eighteen (18) years of age or older and of sound mind, and upon death I hereby certify that: (check the appropriate box and begin the line next to the box)
Because I cannot give instructions regarding life-prolonging treatment and the use of artificial nutrition and hydration, I want this directive to be respected by my treating physician, my family, and any surrogate appointed under this directive. as a final expression of my legal right to refuse medical or surgical treatment and I accept the consequences of refusal.
If I have been diagnosed with pregnancy and this diagnosis is known to my attending physician, this instruction has no force or effect during pregnancy.
I fully understand the importance of this directive and I am emotionally and mentally capable of complying with this directive.
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At the time of our joint participation, the patient, who is of sound mind and at least eighteen (18) years of age, has voluntarily dated and signed this letter or directed it to be dated and signed for the patient.
By using this website, you consent to our use of cookies to analyze web traffic and improve your experience on our website. An OKA living will or health care directive allows a person (director) to create end-of-life treatment benefits. The main purpose of a living will is to direct medical personnel to enable or withdraw life-sustaining procedures. It is only discussed if the person is considered to have a terminal or incurable disease.
A living will is a declaration that instructs medical personnel how to care for a person (the declarant) who is in a terminal or incurable condition. The document includes the declarant’s acceptance or rejection of life support procedures.
Think about how you want to act in the event of certain medical events, such as:
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Based on your personal preferences, do you want the medical staff to do whatever it takes to keep you alive? Or would you prefer to die peacefully without being able to breathe or eat on your own?
These are questions that should be discussed between you and your family, so that you and your family are prepared in the unlikely event that this happens. After careful discussion, the final decisions you make should be reflected in the document.
If you have decisions other than medical care, such as having a priest or religious inform you of your last rights or funeral plans, it’s a good idea to write them down for your family to follow.
Most living wills include the option to include a health care agent to carry out the patient’s wishes. This is useful if there is a gray area where the chosen agent feels it has a good chance of survival and chooses against the decision made by the living will. Otherwise, the director can ignore this part of the document and ensure that the doctors and medical staff follow what is written in the living will.
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The declarant is required to sign the directive in accordance with state law. This usually involves two (2) witnesses or a notary public (or both).
The director is the only signatory required. Although, the State of Idaho recommends that it be witnessed or notarized.
I, [FULL Name] (the “Director”), want everyone who cares about me to know what kind of health care I want if I can’t tell others what I want.
I want my doctor to try treatments that can bring me back to an acceptable quality of life. However, if my quality of life becomes unacceptable to me and my condition does not improve (irreversibly), I will order the withdrawal of all life-prolonging treatments.
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☐ – Even though I have the quality of life described above, I still want to be treated with food and water through a tube or IV (IV).
☐ – If I have the quality of life described above, I do not want to be fed through a tube or intravenously (IV) with food and water.
Some people do not want certain treatments in any situation, even if they are available. Consider the following treatments that you absolutely do not want:
(This section may include preferences such as hospice care, place of death, funeral, cremation, or burial options)
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As a director, I fully understand my rights regarding these lifestyle and health care treatment options. I put my choice over my discretion and I didn’t force any of the 3
(1) Date of documents. The doctors and health professionals responsible for your care will require a recent statement of your treatment preferences. When you have completed this matter, return to the first statement, then write the date you signed this document.
(2) Title of declaration. Some of the topics discussed in this directive may have a significant impact on human health. Because this document is sent when a patient is unable to communicate while suffering from an incurable or incurable serious medical condition, it is important that examining physicians feel favorably about the Declarant issuing this directive. . To identify yourself as a Declarant, you must provide your full name in the first article and provide some supporting information when requested.
(5) Chronic coma or persistent vegetative state. This document can be used as a tool to describe to doctors what you consider to be an unbearable quality of life when you are unable to speak or otherwise express such thoughts and beliefs. For example, if you want doctors to know that you consider being in a lifelong coma or permanent vegetative state to be an unacceptable lifestyle, start the statement on that topic and put an “x” in the appropriate box. If you do not want to make such a statement to doctors who need to review this document in the future, do not mark it.
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(6) I can’t express my needs. Some medical conditions leave you in a state where you are aware of your surroundings and those around you, but unable to communicate. If you want medical professionals to know that such an outcome from any condition cannot be considered a cure because you do not believe you can live this way, then start with the second statement presented.
(7) Never knows family or friends. If your quality of life is closely related to your ability to recognize the people around you as family or friends, you can tell your doctors that the loss of this ability is too debilitating to call for recovery. Begin the third statement by not recognizing friends and family as an unbearable quality of life.
(8) Complete reliance on others for daily care. The fourth statement in this domain is tolerating complete dependence on other people for daily self-care activities (ie, dressing, bathing, brushing, eating, traveling, etc.) defines as an indispensable quality of life. Prioritize this statement to allow doctors to treat you in the future so that they consider this condition to be an unacceptable standard of living.
(9)
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