Utah Living Will
This document, prepared on [DATE], reflects the wishes of [YOUR NAME] regarding my health care and medical treatment preferences in the event I become unable to communicate or make decisions due to incapacity. This Directive is made by the laws of the State of Utah.
I. Principal Details
Name: | [YOUR NAME] |
Address: | [YOUR COMPANY ADDRESS] |
Date of Birth: | [YOUR DATE OF BIRTH] |
II. Health Care Directives
As the declarant, I stipulate the following instructions for my health care plan:
In the event of a terminal condition, I direct that my healthcare providers administer treatment only if it serves the purpose of alleviating pain. I decline any treatments that might extend my life or delay my death, including but not limited to artificial respiration, cardiopulmonary resuscitation, and artificial nutrition and hydration.
If I am in a persistent vegetative state or permanently unconscious, I direct that all life-sustaining treatments, including artificially administered nutrition and hydration, be withdrawn, unless specified otherwise in this document.
I explicitly request that medication be liberally used as necessary for pain relief, even if it hastens my death, within the bounds of medical ethics and the law.
III. Special Directives or Limitations
To specify special directives or limitations for your health care, consider the following guidelines:
III.I. Medical Treatments and Procedures
Specify any medical treatments or procedures you wish to avoid or prefer, such as:
Preferences for resuscitation (CPR) or life support measures.
Preferences for specific medications or treatments.
Avoidance of certain invasive procedures or surgeries.
III.II. End-of-Life Care Preferences
Specify preferences for end-of-life care, including palliative care or hospice.
Indicate your preferences regarding artificial nutrition or hydration.
III.III. Quality of Life Considerations
III.IV. Religious or Spiritual Considerations
III.V. Designation of a Healthcare Proxy
Designate a trusted individual as your healthcare proxy to make decisions on your behalf if you are unable to do so.
III.VI. Communication Preferences
Specify how you wish to be communicated with regarding medical decisions and updates.
III.VII. Special Circumstances or Conditions
Include any specific health conditions or circumstances that require unique considerations.
IV. Appointment of Health Care Agent
I hereby designate the following individual as my health care agent to make medical decisions on my behalf should I become incapable of making my own decisions:
Name: | [AGENT'S NAME] |
Relationship to Declarant: | [RELATIONSHIP] |
Phone Number: | [AGENT'S PHONE NUMBER] |
If the above-named agent is unable, unwilling, or unavailable to act as my agent, I hereby appoint the following alternative agent:
Name: | [ALTERNATE AGENT'S NAME] |
Relationship to Declarant: | [RELATIONSHIP] |
Address: | [ALTERNATE AGENT'S ADDRESS] |
Phone Number: | [ALTERNATE AGENT'S PHONE NUMBER] |
V. Signature and Affirmation
With full understanding of the contents and implications of this Advance Health Care Directive, I hereby provide my signature:
[YOUR NAME]
[DATE SIGNED]
VI. Witnesses
This document was signed in the presence of the following witnesses, who confirm that the declarant is of sound mind and free from duress:
Witness 1:
[WITNESS 1'S NAME]
[DATE SIGNED]
Witness 2:
[WITNESS 2'S NAME]
[DATE SIGNED]
VII. Notarization (Optional)
State of: Utah
Subscribed and sworn (or affirmed) before me by [YOUR NAME], the declarant, and subscribed and sworn (or affirmed) before me by [WITNESS 1'S NAME] and [WITNESS 2'S NAME], witnesses, this [DATE].
Notary Public: [NOTARY PUBLIC'S NAME]
My Commission Expires: [EXPIRATION DATE]
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