Indiana Life-Prolonging Procedures Form

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Updated June 02, 2022

An Indiana life-prolonging procedures will declaration gives official notice to any medical staff treating the patient their intentions of doing everything necessary to prolong their life. This is a form unique to Indiana to help safeguard an individual from having anyone else speak on their behalf in an attempt to end their life.

LawsIC 16-36-4-11

Signing Requirements – Two (2) Witnesses

Related Forms

Medical Power of Attorney (Form 56184) – Allow someone else to make medical decisions on your behalf.

Download: Adobe PDF, MS Word, OpenDocument




Living Will Declaration (Form 55316) – To select end-of-life procedure options such as terminating food and hydration in the case of a terminal illness.

Download: MS Word