Vermont Living Will
I. Introduction
This is my Living Will, made on [DATE], in the State of Vermont.
I, [YOUR NAME], hereby declare this to be my directive concerning my medical treatment preferences if I am unable to communicate my wishes.
II. Statement of Intent
I understand the importance of making my healthcare preferences known, particularly in situations where I am unable to express them myself.
It is my desire that this Living Will be honored by my healthcare providers and any individuals responsible for making medical decisions on my behalf.
III. Declaration of Preferences
1. Artificial Nutrition and Hydration:
I hereby state that if I am unable to consume food or fluids orally and require artificial nutrition and hydration, I [choose/prefer]:
[Option 1: Consent to artificial nutrition and hydration under all circumstances.]
[Option 2: Do not consent to artificial nutrition and hydration and wish to rely solely on comfort measures.]
[Option 3: Consent to artificial nutrition and hydration only if it is determined that I have a reasonable chance of recovery.]
2. Ventilator Use:
In the event that I am unable to breathe independently and require mechanical ventilation, I [choose/prefer]:
[Option 1: Consent to the use of a ventilator under all circumstances.]
[Option 2: Do not consent to the use of a ventilator and prefer natural breathing, even if it may shorten my life.]
[Option 3: Consent to the use of a ventilator temporarily, but if it is determined that recovery is unlikely, I wish to be removed from the ventilator.]
3. Cardiopulmonary Resuscitation (CPR):
Should my heart stop beating or I stop breathing, I [choose/prefer]:
[Option 1: Consent to CPR and all life-saving measures under all circumstances.]
[Option 2: Do not consent to CPR or any invasive resuscitative measures and prefer a natural death process.]
[Option 3: Consent to CPR initially, but if it is determined that my condition is terminal or irrecoverable, I wish for CPR to be withheld.]
IV. Appointment of Healthcare Agent
In addition to this Living Will, I have appointed [name of appointed healthcare agent] as my healthcare agent to make medical decisions on my behalf in accordance with my wishes as outlined in this document.
V. Revocation of Previous Documents
I hereby revoke any prior Living Wills or similar documents I may have executed.
VI. Signature and Witness
Signed on [DATE] in the presence of the undersigned witnesses:
Testator
[YOUR NAME]
[YOUR COMPANY ADDRESS]
Witness #1
Name: [WITNESS NAME 1]
Address: [WITNESS ADDRESS 1]
Witness #2
Name: [WITNESS NAME 2]
Address: [WITNESS ADDRESS 2]
VII. Notarization (if applicable)
Notary Public Name: [NOTARY'S NAME]
Commission Expires: [EXPIRATION DATE]
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