Medical Living Will Form

I. Declaration

I, [Your Name], residing at [Your Address], being of sound mind and legal capacity, hereby declare this document as my Medical Living Will. It reflects my healthcare treatment preferences should I be unable to communicate them due to terminal illness, injury, or other incapacitating conditions.

II. Medical Preferences and Directives

Life-Sustaining Treatment

If I am in a terminal condition or permanently unconscious and cannot make my own medical decisions, I direct that the following life-sustaining treatments be provided:

• Resuscitation

• Mechanical Ventilation

• Artificial Nutrition and Hydration

Palliative Care

If I am in a terminal condition or permanently unconscious and cannot make my own medical decisions, I request that palliative (comfort) care be provided to relieve suffering, even if it may hasten my death.

III. Appointment of Healthcare Proxy

In the event that I am unable to make medical decisions for myself, I appoint [Proxy Name], residing at [Proxy Address], to make healthcare decisions on my behalf. If the above-named healthcare proxy is unable or unwilling to act, I appoint [Alternative Proxy Name] to act as my alternate healthcare proxy.

IV. Additional Instructions

V. Signatures

I, [Your Name], the principal, have signed this Medical Living Will on this [Month Day, Year], in the presence of the undersigned witness who affirm that I did so willingly and in sound mind.

Name:

Date:

Witness Signature:

Name:

Date:

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