Living Will (Declaration)

Who is this for?

You will be known as the "principal" on this document.

What are your priorities for end-of-life? (check all that apply)

Minimizing pain and discomfortStaying medically alive for as long as possibleAvoiding invasive proceduresBeing independent and of sound mind

If medical staff believe that you are in pain, do you want to be given drugs for pain relief even if it may hasten death?

YesNo

Do you want to stop receiving life support under certain conditions?

YesNo

i.e. If you are in a vegetative state or coma; your condition is determined to be irreversible, etc.

I do not want life support if I am: (check all that apply)

In a coma or vegetative stateNo longer able to communicate my needsNo longer able to recognize family or friendsTotally depending on others for daily careOther

Explain:

Are there any procedures you do NOT want under any circumstance?

Yes, there are certain procedures I do not want.No, I want all life-sustaining procedures.

e.g. CPR, dialysis, ventilation, etc.

I do not wish to have the following treatments under any condition: (check all that apply)

Cardiopulmonary Resuscitation (CPR)Ventilation (breathing machine)Feeding tubeDialysisOther

Other:

Are there any other wishes that you want to add to your end-of-life treatment?

YesNo

Add the following medical requests:

Would you like to enter your mailing address?

YesNo

Your mailing address may be required depending on the state you live in.

Your mailing address

Street Address

Address Line 2

City

State

ZIP Code

Would you like to add a Medical Power of Attorney?

YesNo

A Medical POA allows you to appoint an agent to make medical decisions on your behalf when you are unable to.

Who will be your agent?

Phone number

Email address

Add the agent's address now?

YesNo, I will enter it later.

Agent's mailing address

Street Address

Address Line 2

City

State

ZIP Code

Do you want to appoint an alternate agent?

YesNo

In case the original agent is unavailable or unwilling to make a decision on the patient's behalf.

Name of alternate agent

Phone number

Mailing address

Street Address

Address Line 2

City

State

ZIP Code

Do you want to appoint a second alternate agent?

YesNo

In case both the original agent and the first alternate agent are unavailable or unwilling to make a decision on the patient's behalf.

Name of second alternate agent

Phone number

Mailing address

Street Address

Address Line 2

City

State

ZIP Code

When will the agent's powers become effective?

Upon the principal's incapacitationImmediately

Typically, the agent is granted power upon the principal's incapacitation.

When will the agent's powers become terminated?

Upon the principal's deathOn a specified end date

Most commonly, the agent's powers are terminated upon the patient's death.

Enter the end date:

Will the agent be granted access to your medical records?

YesNo

In accordance with HIPAA (Health Insurance Portability and Accountability Act) of 1996.

Will there be any limitations to the agent's powers?

Yes, there will be limitations.No, there will not be any limitations.

Without any limitations, the agent may have the power to choose to withdraw life-sustaining care, drinking, and/or feeding.

The agent is authorized to make all healthcare decisions for me, except as I state here:

Will the agent have certain authorities after your death?

YesNo

Related to donating organs, authorizing an autopsy, and the direct disposition of the remains.

Will there be any exceptions to this?

YesNo

List the exceptions:

Do you wish to donate any of your organs after your death?

YesNo

Which parts of the body may be donated?

All parts of the bodyOnly specified organs

List the following body parts that may be used for organ donation:

The principal's organs may be used for:

TransplantTherapyResearchEducation

Do you want to enter your primary care physician's information?

YesNo

Physician's name

Phone number

Office address

Street Address

Address Line 2

City

State

ZIP Code

Where will copies of this medical power of attorney will be held?

I am a resident of

Under state law, the principal is required to sign this document in the presence of two witnesses.

I understand.

The two witnesses cannot be related by blood, be a beneficiary of the patient's estate, or be medical staff.

Under Arizona law, the principal is required to sign in the presence of one witness or a notary public.

I understand.

If the patient decides to sign in front of a witness, the witness cannot be blood-related, medical staff, or a beneficiary in the patient's will.

Under Utah law, the principal is required to sign in the presence of one witness.

I understand.

The witness can be a notary public but cannot be a person who is blood-related, a beneficiary in the patient's will, or medical staff.

Under state law, the principal is required to sign with either two witnesses or a notary public.

I understand.

If the patient decides to sign with two witnesses, they cannot be blood-related, a beneficiary in the patient's will, or medical staff.

Under state law, the principal is required to sign with two witnesses and a notary public.

I understand.

Under state law, the principal is only required to sign. However, it is recommended to sign in the presence of a notary public.

I understand.

If the document is notarized, no third party will be able to claim that the patient did not sign out of their own free will. A notarization legitimizes any document as being signed by the actual signer.