Living Will

Living Will of YOURFULLNAMEHERE

Date: XXDATEHEREXX

I, XXYOURFULLNAMEHEREXX, being of sound mind, make this statement as my living will to express my wishes for medical treatment in case I become unable to communicate my decisions. I have provided choices below so that my preferences can be clearly documented.

1. Life-Sustaining Treatment

If I have an incurable or irreversible condition that will result in my death within a short period:

☐ I do not wish to receive mechanical ventilation (Life Support - A machine (ventilator) helps a person breathe when they cannot do so on their own.)

☐ I do not wish to receive dialysis (A treatment to filter waste and excess fluids from the blood when the kidneys are no longer functioning properly.)

☐ I do not wish to receive antibiotics and antiviral medications (Used to treat severe infections that might otherwise be fatal, such as sepsis or pneumonia.)

☐ I do not wish to receive blood transfusions (Transfusions to replace lost blood, improve oxygen delivery, or address severe anemia.)

☐ I do not wish to receive surgeries and invasive procedures (Procedures aimed at prolonging life, such as heart bypass surgery, inserting stents, or emergency surgeries to address internal bleeding.)

☐ I do not wish to receive chemotherapy or radiation therapy (Aggressive treatments for cancer intended to prolong life, even when a cure is not possible.)

☐ I do not wish to receive defibrillation and pacemaker (Devices to manage or restart heart rhythms: Defibrillation: Shock delivered to restart the heart during cardiac arrest or Pacemakers: Devices implanted to regulate heartbeats.)

☐ I do not wish to receive oxygen therapy (Supplemental oxygen provided to maintain adequate oxygen levels in cases of respiratory failure.)

☐ I do not wish to receive tracheostomy (A surgical procedure to create a hole in the throat (trachea) to help a person breathe, often connected to a ventilator.)

☐ I do not wish to receive blood pressure support (Medications to maintain blood pressure in critically ill patients when the body cannot regulate it naturally.)

☐ I do not wish to receive heart-lung machine (ECMO) (Machines used in critical care to take over heart and lung functions temporarily, often used during surgeries or severe heart failure.)

☐ I do not wish to receive palliative surgery (Procedures to relieve pain or discomfort that indirectly sustain life, such as surgeries to relieve obstructions or prevent infections.)

☐ I do not wish to receive total parenteral nutrition (TPN) (Feeding through a vein when the digestive system cannot process food.

☐ I wish to receive life-sustaining treatment to prolong my life as much as possible, regardless of the prognosis.

2. Resuscitation

If my heart stops (cardiac arrest):

☐ I do not wish to be resuscitated (Do Not Resuscitate - DNR).
☐ I wish to be resuscitated and have all possible measures taken.

3. Artificial Nutrition and Hydration

If I am unable to eat or drink on my own:

☐ I do not wish to receive artificial nutrition and hydration, unless it is necessary for comfort care.
☐ I wish to receive artificial nutrition and hydration to sustain my life.

4. Pain Management and Comfort Care

☐ I do not wish to receive pain management or medications that could shorten my life.
☐ I wish to receive pain management and comfort care, even if it may shorten my life.

5. Organ Donation

After my death:

☐ I wish to donate my organs and tissues for transplantation or medical research.
☐ I do not wish to donate my organs or tissues.

6. Healthcare Proxy (Optional)

I appoint the following person to make medical decisions on my behalf if I am unable to do so:

• Primary Proxy Name: ___________________________

• Relationship: ___________________________

• Phone: ___________________________

If the person above is unavailable, I appoint:

• Alternate Proxy Name: ___________________________

• Relationship: ___________________________

• Phone: ___________________________

Signature and Witnesses

I make this document of my own free will and ask my family, caregivers, and medical team to respect my choices.

Signature: ________________________________
Date: ________________________________

Witness 1:
Signature: ________________________________
Date: ________________________________

Witness 2:
Signature: ________________________________
Date: ________________________________

Notary (if required in your state)

State of ______________________
County of _____________________

Subscribed and sworn before me this _______ day of ______, 20.

Notary Public: ________________________________
My Commission Expires: ________________________________