Ohio Living Will Form | Declaration

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Updated June 01, 2022

An Ohio living will is a declaration stating a person’s preference to receive life-sustaining treatments or die a natural death. This would only come into effect if the declarant is in a terminal and incurable condition where the only recourse is pro-longing an unavoidable death. A living will is commonly completing with a medical power of attorney that allows a person to select an agent to make health care decisions on their behalf.

Laws

How to Write

Download: Adobe PDF

Step 1 – Download the document. The Declarant/Principal must carefully read the section located on the first page of the document, so that they may be better informed regarding what to expect by completing this document.

Step 2 – Establishment of Declarant – Enter the following at the top of the second page of the document:

  • Print the Declarant’s Full Legal Name
  • Enter the Declarant’s Dte of Birth in mm/dd/yyyy format
  • The Declarant should take the time to review the definitions that will be found throughout the document. You may refer back to them at any time if you need to be clear.
  • If at any point this document becomes overwhelming or you do not understand, consider a consultation with an attorney.
  • At the end of the definitions, you will be asked if you have completed a power of attorney before, simply check yes or no in the box provided on teh form

Step 3 – Before the Declarant continues with the completion of the form, read the notification.   [R.C.   §2133.05(2)(a)]

Step 4 – Contact Information – If the Declarant should decide against use of this section, simply place an “X” through this section. If the Declarant wishes to provide this information, complete this area as follows:

  •  First  contact’s  name  and  relationship
  •  Address
  • Telephone  number(s)
  • AND
  • Second  contact’s  name  and  relationship
  • Address
  • Telephone  number(s)
  • AND
  • Third  contact’s  name  and  relationship
  • Address:
  • Telephone  number(s)

Step 4 – Declarant’s Authorization to Physician- For  the  purpose  of  providing  comfort  care,  I  authorize  my  physician  to:

  • For  the  purpose  of  providing  comfort  care,  I  authorize  my  physician  to:
  •  Administer  no  life-­‐sustaining  treatment,  including  CPR
  • Withhold  or  withdraw  artificially  or  technologically  supplied  nutrition  or  hydration,  provided   that,  if  I  am  in  a  permanently  unconscious  state,  I  have  authorized  such  withholding  or   withdrawal  under  Special  Instructions  below  and  the  other  conditions  have  been  met
  • Issue  a  DNR  Order
  • Take  no  action  to  postpone  my  death,  providing  me  with  only  the  care  necessary  to  make  me   comfortable  and  to  relieve  pain.

Step 5 – Special Instructions – If the Declarant has special instructions they would like to interject as stated, initial the box provided

Step 6 – Additional  instructions  or  limitations – Enter any additional instructions into the box provided. If more space is required, continue on a separate sheet and attach it to the document

Step 7 – Anatomical Gift  (optional) – The “anatomical gift” language provided is required by ORC §2133.07(C)

  • Should the Declarant wish to provide anatomical gifts, check the boxes in this section that you would like to donate
  • Specify how you would like your gifts to be used
  • Notify all family members, physicians etc. Read the statement, if in agreement provide the following:
  • Date the Declarant’s Signature in mm/dd/yyyy format
  • Enter location in which the declaration is being signed
  • Enter the Declarant’s Signature

Step 8 – The Declarant may choose whether they would prefer two witnesses OR a notary public as witness:

  • Should the Declarant choose witnesses, it’s vital that they understand what is unacceptable as a witness for your protection:
  • WITNESSES  [R.C.  §2133.02(B)(1)]
  • [The  following  persons  CANNOT  serve  as  a  witness  to  this  Living  Will  Declaration
  • Your  agent  in  your  Health  Care  Power  of  Attorney,  if  any
  • The  guardian  of  your  person  or  estate,  if  any
  • Any  alternate  agent  or  guardian,  if  any
  •  Anyone  related  to  you  by  blood,  marriage  or  adoption  (for  example,  your     spouse  and  children)
  • Your  attending  physician
  • The  administrator  of  the  nursing  home  where  you  are  receiving  care

Step 9 – Should you decide to use two witnesses, they must enter the following information:

Witness 1-

  • Witness  One’s  Signature
  • Witness  One’s  Printed  Name
  • Date in mm/dd/yyyy format
  • Witness  One’s  Address

Witness 2 –

  • Witness  Two’s  Signature
  • Witness  Two’s  Printed  Name
  • Date in mm/dd/yyyy format
  • Witness Two’s  Address

If the Declarant prefers a Notary Public as witness, the notary will complete the remainder of the document and acknowledge with their state seal.

Step 10 – State  of  Ohio Donor  Registry  Enrollment  Form Notice  to  Declarant – If the Declarant would like to be an organ donor you must read the following and then complete the form.

Step 11 – Additional Information Included in this Packet

  • Ohio’s Do Not Resuscitate Laws
  • The Hospice Choice