eForms Logo

North Carolina Living Will Form

Create a high-quality document now!

North Carolina Living Will Form

Updated August 03, 2023

A North Carolina living will instructs a medical staff on a person’s desires to receive or withhold medical treatment. This is in the event of permanent incapacitation or an incurable condition. In most cases, the form directs their primary care physician to withhold life-supporting treatments and die a natural death.


How to Write

Download: PDF

Step 1 – Download the document. The Declarant must carefully review the information in the first box in order to acquire a clear understanding of what is to be completed and signed. When the Declarant feels they understand, move to section two

Step 1 – Declarant’s Desire for a Natural Death –

  • Enter the Declarant’s full legal name

Step 2 – When the Declarant’s Apply – Read the following statement then initial any or all that apply just below the statement in the fields provided

“My directions about prolonging my life shall apply IF my attending physician determines that I lack capacity to make or communicate health care decisions”

Step 3 – These are the Declarant’s Directives About Prolognging Their Life – Read the following statement then initial only one that applys just below the statement in the fields provided:

In those situations I have initialed in Section 1, I direct that my health care providers:

Step 4 – Artificial Nutrition and Hydration – Initial any part of this section only if you wish to make any exceptions to your previous instructions to section 2. Read the statement and then initial the possible statements in the fields provided

“EVEN THOUGH I do not want my life prolonged in those situations I have initialed in Section 1:

Step 5 – Read read the following statement:

“I direct that my health care providers take reasonable steps to keep me as clean, comfortable, and free of pain as possible so that my dignity is maintained, even though this care may hasten my death. ”

“I Understand my Advance Directive and I am aware and understand that this document directs certain life-prolonging measures to be withheld or discontinued in accordance with my advance instructions.”

Step 6 – If I Have an Available Agent – Read the following statement and indicate your preference by initialing only one of the fields provided on the form:

“If I have appointed a health care agent by executing a health care power of attorney or similar instrument, and that health care agent is acting and available and gives instructions that differ from this Advance Directive, then I direct that:”

Step 7 – Reliance of Health Care Provider Upon This Declarants’s Documented Wishes – Read the information in the paragraph. No action need be taken inasmuch as it will be acknowledged by witness at the end of the document. Nonetheless, the Declarant should read and agree. If at any point there is any confusion with regard to the meaning of any of this document, the Declarant may consider calling on the services of a qualified attorney.

“My health care providers shall not be liable to me or to my family, my estate, my heirs, or my personal representative for following the instructions I give in this instrument. Following my directions shall not be considered suicide, or the cause of my death, or malpractice or unprofessional conduct. If I have revoked this instrument but my health care providers do not know that I have done so, and they follow the instructions in this instrument in good faith, they shall be entitled to the same protections to which they would have been entitled if the instrument had not been revoked.”

Step 8 – This Directive, is Ordered by the Declarant to be in Effect Anywhere –

“I intend that this Advance Directive be followed by any health care provider in any place.”

Step 9 – I have the Right to Revoke this Direction – You do have the right to revoke this document at any time, as long as you are of sound mind to do so. The moment you decide that this is not what your wishes are, let someone know immediately or contact your attorney. This is the protection of your rights.

  • I understand that at any time I may revoke this Advance Directive in a writing I sign or by communicating in any clear and consistent manner my intent to revoke it to my attending physician. I understand that if I revoke this instrument I should try to destroy all copies of it.
  • Date the reading of this statement and your signature, in dd/mm/yyyy format
  • Enter Declarant’s Signature
  • Type or Print Declarant’s Name

Step 10 – Witnesses and Notarization- The Declarant must have two witnesses sign the document that are in no way related by blood, marriage or otherwise: First, provide the dated signatures of the witnesses:

Witness 1 –

  • Date in mm/dd/yyyy format
  • Signature of Witness

Witness 2 –

  • Date in mm/dd/yyyy format
  • Signature of Witness

The remainder of the form must be completed at the hand of a licensed notary public, as required by North Carolina Law. The document will be acknowledged by the notary public’s state seal.