LIVING WILL

TEMPLATE

In the event that the time comes and I am incapacitated to the point that I am no longer able to actively take part in decisions for my own life, and I am unable to direct my healthcare physician as to my own medical care, I hereby authorize this Living Will as my Advance Health Care Directive to stand as a testament of my wishes.
 
I,______________________, residing at _____________, in the County of ___________, in the State of ___________, in the postal code _____________, and whose telephone number is ______________, being of sound mind, and acting willingly and without duress, fraud or undue influence, herein direct that the instructions provided herein are to be recognized as a formal statement of my desires with regards to my health care, custody and medical treatment, and as such I hereby voluntarily declare and make this designation with regards to my Living Will (aka Advance Health Care Directive and/or Health Care Proxy). These instructions and directives shall be binding upon all involved to the fullest extent allowable by law.

 

DESIGNATION OF HEALTH CARE ADVOCATE/PROXY
 
I herein designate ____________________ residing at ____________, and whose telephone number is ____________ as my advocate /proxy and agent to make any and all health care decisions on my behalf should I ever be diagnosed with a terminal illness, disease, injury, or should I become incapacitated or permanently unconscious (in a coma or persistent vegetative condition) where I would remain permanently unable to make decisions.
I have specific directives regarding the delivery of medical care in certain health care conditions. Therefore, I wish to direct my medical treatment by way of the following conditions:

LIFE-SUSTAINING MEDICAL TREATMENT

Should any of the aforementioned events occur, I wish to leave the following directives regarding the treatment and procedures which may be used, withheld or withdrawn:


1. In the event I develop Dementia and I reach a state where I could not take any oral feed I wish not to have tube feeds / I wish to have tube feeds.
2. If I become too sick to take oral feeds due to age related frailty I wish not to have tube feeds even if it may hasten my death/ I wish to have tube feeds.
3. If I am diagnosed with a cancer affecting my brain and I slip into coma I wish not to have tube feeds and tubes if already in place should be removed within one week/I wish to have tube feeds.
4. If I become comatose following a stroke or head injury and remain in coma for more than one month I wish to have my feeding tubes removed even if it may hasten my death/ I wish to have feeding tubes till my recovery or death.
5. If I become bed ridden due to age related frailty, dementia, multiple stroke, head injury or terminal cancer I wish not to have antibiotics for chest infection even if it may hasten my death. / I wish to have antibiotics.
6. If I become bed ridden due to age related frailty, dementia, multiple stroke, head injury or terminal cancer and I develop low sodium in blood I wish not to have correction of low sodium state by IV fluids/ I wish to have IV fluids for sodium correction.
7. If I become bed ridden due to age related frailty, dementia, multiple stroke, head injury or terminal cancer and I develop low oxygen levels in blood I wish not to have ventilator support even if it may hasten my death. /I wish to have ventilator support.
8. If I become bed ridden due to age related frailty, dementia, multiple stroke, head injury or terminal cancer and I develop end stage renal disease I wish not to have dialysis even if it may hasten my death/I wish to have dialysis.
9. If I become bed ridden due to age related frailty, dementia, multiple stroke, head injury or terminal cancer and I develop sudden cardiac arrest I wish not to undergo cardio pulmonary resuscitation even if it may hasten my death/ I wish to have CPR.
10. If I become bed ridden due to age related frailty, dementia, multiple stroke, head injury or terminal cancer and I develop severe anaemia I wish not to have blood transfusion/I wish to have blood transfusion.
11. If I become bed ridden due to age related frailty, dementia, multiple stroke, head injury or terminal cancer and I develop organ failures I wish not to have organ transplantation.

By my signature below, in front of the witnesses identified below, I hereby execute and subscribe to the declarations made in this Living Will both freely and voluntarily, and wholeheartedly request that my family, physician(s), attorney, and any other individuals who may in the future become responsible for my health and well-being and any decisions related thereto, whether partly or fully, all abide by my wishes as stated herein.

 

_________________________________                ______________
[NAME]                                                               [DATE]

This Living Will was signed by [NAME] in the presence of the following individuals, who by their signatures below, confirm that [NAME] was, at the time this document was signed, at least eighteen years of age, of sound mind, memory, disposition, understanding, and able to understand the weight of this health care decision, and not under any improper influence. The undersigned witnesses have subscribed this document in [NAME]’s presence and in each other’s presence at [NAME]’s request.

[WITNESS NAME]
[ADDRESS]

_________________________________                _____________
                                                                          [DATE]

 


[WITNESS NAME]
[ADDRESS]

_________________________________                ______________

                                                                         [DATE]

 

1. This document will not need to be executed on stamp paper. 
2. Persons signing as Witnesses can also be the Authorized Attorneys.