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Living Will Form

ADVANCE CARE DIRECTIVE (LIVING WILL)
To: My Family, my Physicians, my Lawyer, any Medical Facility in whose care I happen to be, any Individual who may become responsible for my Health Affairs, and All Others Whom It May Concern:

1.  Print Name: _____________________________________________________________   Birth Date: ____________________

Address: ______________________________________________________   Social Security #: ___________________________

2.  I, ______________________________________________ , being of sound mind, make this statement as instructions to be followed if I become permanently unable to participate in decisions regarding my medical care. These instructions reflect my firm decision to decline medical treatment under the following circumstances indicated below. 

3.  If I have an incurable or irreversible condition that renders me incapable of making decisions on my own and there is no reasonable expectation that I will recover, then I direct my attending physician to withhold or withdraw treatment that only prolongs my dying.

These instructions only apply if:  (Check those statements you agree with:)

q  I am in a terminal condition
q  I am minimally conscious with irreversible brain damage
q  I have Alzheimer's or another form of dementia
q  I am permanently unconscious
q  Other  ___________________________________________________

I instruct that my treatment be limited to measures to keep me comfortable and to relieve pain.

While I understand that I am not legally required to be specific about future treatments, if I am in the conditions) described above I have strong beliefs about the following forms of treatment:  (Check those statements that you agree with:)

q I do not want cardiopulmonary resuscitation (CPR).
qI do not want mechanical ventilation (respirator).
q I do not want artificial nutrition and hydration (intravenous fluids or feeding tube).
qI do not want medical treatment (antibiotics/other medications) unless they are necessary for my comfort.
q I do not want hospitalization.

4.  Other directions/instructions that you wish to add (for additional space, use the bottom or back of this form):

_________________________________________________________________________________________________________

5.  These express my legal right to refuse treatment, under the law in New York. I intend my instructions to be carried out unless I have changed them in writing or by clearly indicating that I have changed my mind.

Signed: _________________________________________  Today's Date: __________________
(Sign and Date this document)

6.  Witness (must be two (2) adults).    I declare that the person who signed this document is known to me and is acting of his/her own free will. He/she signed (or asked another to sign for him/her) this document in my presence.

Witness #1 
Your signature: ____________________________     Print Name: _______________________________ Today's Date: ____________

Witness #2
 Your signature: ____________________________     Print Name: _______________________________ Today's Date: ____________