Living Will
WRITING YOUR LIVING WILL
If you will bear with me, I wish to discuss a difficult subject. I want to talk with you about your death. It is not a pleasant subject and few people want to think about it. Unfortunately for a few of us, the end will come early and unexpectedly. If you are unable to communicate your desires, does your family know your wishes? Who will make the decisions for you? Will there be conflicts? Will those decisions be the ones you would have made?
Dealing with those questions today brings up difficult choices that youâd probably rather not think about but we all saw the horrible nightmare that Terri Schiavoâs family went through when she was unable to make decisions for herself regarding her health care. If you want to keep Tom DeLay out of the most personal of all decisions, it is important that you set your wishes and desires down now while you can.
I know it is an uncomfortable and subject to deal with, but it is something we all need to think about. To that end, I have prepared a working document that can help you to communicate your wishes to the people around you and to your doctors.
Please remember that physicians have legal obligations regarding your treatment that may conflict with your wishes, and with malpractice these days they must protect themselves from lawsuits from family members who may be caught up with their own feelings of grief and loss as happened to the Schiavo family. The clearer your expression of desire is under these circumstances, the easier it is for everyone to accede to your wishes.
The document that follows is by no means a bullet-proof legal document, and I am not offering legal advice here, but most courts and medical authorities will respect your expressed wishes so long as they do not conflict with state law.
The ideas in the draft Living Will are suggestions. They are a beginning. They are intended to cover many situations and to give you ideas you may not have thought about on your own. Change and modify as you wish - this is your document, so please make it so. Spend some time really thinking about what you want.
Many states have passed living will laws, so be sure that your requests conform with your state law. As an example, your state may use another term for Health Care Agent or, your state may have a different way of determining whether or not you are able to make health care choices, who may be a witness, etc. It would be a good idea to make a few telephone calls to be sure that what you have expressed in your Living Will does not conflict with decisions made by your state government.
Choosing a Health Care Agent:
Choose someone who knows you very well, cares about you and can make difficult decisions. Make sure that this person agrees to respect your wishes. A spouse or family member is often not a good choice because they will likely be emotionally involved in what is happening. Choose someone who will stand up for you against the system or even your family if necessary so that your wishes will be followed.
Also, choose someone who lives fairly close so that they can be there when you need them. They should be at least 18 years old and should not be financially involved in the distribution of your estate. They also should NOT be your health care provider or the owner or operator of a health care or residential facility serving you, or an employee of your health care provider. Someone serving as a proxy for a number of other people is also not a good choice.
It is likely that your partner will have control of the checkbook and by the Living Will you will have granted decision making to your Health Care Agent. That can be a source of substantial conflict unless these things are discussed and clarified ahead of time.
If you change your mind about having a Health Care Agent, or any other part of the Will, destroy all copies of it and make a new document. Tell your doctor and family about the changes you have made and document those changes.
You can write the word REVOKED in large letters across the name of each agent whose authority you want to cancel or the section you want to change. Then sign your name and date on that page.
Distribute this document openly so that your family, friends and physicians are clearly aware of your desires. Do NOT keep a single copy of this document locked away someplace like a safe-deposit box. You might want to record who has copies of your Living Will so that if you make changes you can be sure everyone receives an updated copy or are at least notified that you have made changes.
Update your Living Will as your desires change and especially if there are changes to the lives or domiciles of your Health Care Agent(s) or witnesses.
LIFE SUPPORT
If you wish to limit the meaning of life-support treatment because of religious or personal beliefs, make the appropriate changes in that section.
RESUSCITATION
Many states require that you have a DO NOT RESUSCITATE form signed by a doctor and/or a DO NOT RESUSCITATE bracelet if you do not desire these procedures. This lets emergency personnel know your wishes. Check with your doctor.
WITNESSES
Some states have specific rules about who can be witnesses.
Notarization of a Living Will is required for residents of Missouri, North Carolina, Tennessee and West Virginia.
Your Comments and Ideas
Basic Living Will
(Copy and Paste into a word
document,
or right click on the PDF
Icon to
download
the PDF)
THE LIVING WILL OF ___________________
MY HEALTH CARE AGENT
If I am no longer able to make my own health care decisions, this form names the person I choose to make those choices for me. This person will be my Health Care Agent. This person will make health care choices if both these things happen:
1. My attending or treating doctor finds I am no longer able to make health care choices, AND
2. Another health care professional agrees that this is true.
THE PERSON I CHOOSE AS MY HEALTH CARE AGENT IS:
_________________________________________ ________________
First Choice Name Phone
______________________________________________________________
Address City, State & Zip
If this person is not able or willing to make these choices for me, OR is legally separated or divorced from me, OR this person has died, these people are my next choices:
_________________________________________ _______________
Second Choice Name Phone
Address City, State, & Zip
_________________________________________ _______________
Third Choice Name Phone
Address City, Sate & Zip
I understand that my Health Care Agent can make health care decisions for me. I want my agent to be able to do the following: (delete anything you do not want your agent to do, or add, etc.)
Make choices for me about my medical care or services, like tests, medicine or surgery. This care or service could be to find out what my health problem is, or how to treat it. It can also include care to keep me alive. If the care or treatment has already started, my Health Care Agent can keep it going or have it stopped.
Interpret any instructions I have given in this form or given in other discussions, according to my Health Care Agent's understanding of my wishes and values.
Arrange for admission to a hospital, hospice or nursing home for me. My Health Care Agent can hire any kind of health care worker I may need to help or take care of me. My Agent may also fire a health care worker if needed.
Make the decision to request, take away or not give medical treatments, including artificially-provided food and water, and any other treatments to keep me alive.
See and approve release of my medical records and personal files. If I need to sign my name to get any of these files, my Health Care Agent can sign for me.
Move me to another state to get the care I need or to carry out my wishes.
Authorize or refuse to authorize any medication or procedure.
Take any legal action needed to carry out my wishes.
Donate tissues as I request that are allowed by law.
Apply for Medicare, Medicaid or other programs or insurance benefits for me. My Health Care Agent can see my personal files, like bank records, to gather information to fill out these forms.
(List any additions below:)
THE KIND OF MEDICAL TREATMENT I WANT:
I believe that I should be treated with dignity. When the time comes that I am very sick and I am not able to speak for myself, I want the following wishes and any other directions that I have given to my Health Care Agent, to be respected and followed:
I do not want to be in pain. I want my doctor to give me sufficient medication to relieve my pain, even if that means that I will be drowsy or sleep more than I would otherwise.
I do not want anything done or omitted by my doctors or nurses with the intention of taking my life.
I want to be offered food and fluids by mouth and kept clean and warm.
LIFE SUPPORT means any medical procedure, device or medication to keep me alive. Life-support treatment includes: medical devices put in me to help me to breathe; food and water supplied by medical device (tube feeding); cardiopulmonary resuscitation (CPR); major surgery; blood transfusions/ dialysis; antibiotics; and anything else meant to keep me alive.
The kind of medical treatment I desire or do not want is expressed below. I want my Health Care Agent, my family, my doctors and other health care providers, my friends and others to know these directions:
When Close To Death:
If my doctor and another health care professional both decide that I am likely to die within a short period of time, and life-support treatment would only delay the moment of my death, (Select one of the following or enter your own wishes):
I want life-supporting treatment.
I do not want life-support treatment. If it has been started, I want it stopped.
I want to have life-support treatment if my doctor believes it could help. But I want my doctor to stop giving me life-support treatment if it is not helping my health condition or symptoms.
In a Coma and not expected top wake up or recover:
If my doctor and another health care professional both decide that I am in a coma from which I am not expected to wake-up or recover, and I have brain damage, and life-support treatment would only delay the moment of my death, (Select one of the following or enter your own wishes):
I want to have life-support treatment
I do not want life-support treatment. If it has been started, I want it stopped.
I want to have life-support treatment if my doctor believes it could help. But I want my doctor to stop giving me life-support treatment if it is not helping my health condition or symptoms.
Permanent and severe brain damage and not expected to recover:
If my doctor and another health care professional both decide that I have permanent and severe brain damage, (for example I can open my eyes but I cannot speak or understand, and I am not expected to get better, and I have brain damage, and life-support treatment would only delay the moment of my death, (Select one of the following or enter your own wishes):
I want to have life-support treatment
I do not want life-support treatment. If it has been started, I want it stopped.
I want to have life-support treatment if my doctor believes it could help. But I want my doctor to stop giving me life-support treatment if it is not helping my health condition or symptoms.
In another condition under which I do not wish to be kept alive:
If there is another condition under which you do not wish to have life-support treatment, identify or describe it here. For example, you might identify "end stage condition" which means that your health has gotten worse, you are not able to take care of yourself in any way mentally or physically. Life-support treatment will not help you recover. You might say:
I do not wish to have life-support treatment. In this condition I believe that the costs and burdens of life-support treatment are too much and not worth the benefits to me. Therefore in this condition, I do not want life-support treatment.
MY COMFORT
I believe that I should be treated with dignity near the end of my life. I understand that others may not be able to do these things or that they may not be required by law to do them.
I do not want to be in pain. I want my doctor to give me sufficient medication to relieve my pain, even if that means that I will be drowsy or sleep more than I would otherwise.
If I show signs of depression, nausea, shortness of breath, or hallucinations, I want my caregivers to do whatever they can to help me.
I wish to have a cool moist cloth placed on my head if I have a fever.
I want my lips and mouth kept moist to stop dryness.
I wish to have warm baths often. I wish to be kept fresh and clean at all times
I wish to be massaged with warm oils as often as I can be.
I wish to have my favorite music played if possible until my time of death.
I wish to have personal care like shaving, mail clipping, hair brushing and teeth brushing as long as they do not cause me pain or discomfort.
I wish to have readings I have selected read aloud when I am near death.
How I Wish To Be Treated
I wish to have people with me when possible. I wish to have someone with me when it seems that my death may come at any time.
I wish to have my hand held and to be talked to when possible, even if I do not seem to respond to the voice or touch of others.
I wish to have others at my side praying for me when possible.
I wish to be cared for with kindness and cheerfulness, not sadness.
I wish to have pictures of my loved ones in my room, near my bed.
If I am not able to control my bowel or bladder functions, I wish for my clothes and bed linens to be kept clean and for them to be changed as soon as possible if they have been soiled.
I would like to die in my home, if possible.
What I Want My Loved Ones To Know:
I wish my family and friends to know that I love them.
I ask my family members to make peace with each other before my death.
I ask my friends and family to remember what life was like before I became seriously ill.
I ask my family, friends and caregivers to respect my wishes, even if they do not agree with them.
After my death I would like my body to be (buried) (cremated), and my remains should be placed in the following location ___________________________.
The following person knows my funeral wishes ______________________________.
If there is to be a memorial service for me, I wish it to include the following (list music, readings or any other specific requests that you may have).
Add any other specific wishes - (the donation of body parts, for example)
SIGNATURE
I _____________________, ask that my family, my doctors and other health care providers, my friends and all others, follow my wishes as communicated by my Health Care Agent or as is otherwise expressed in this form. This form becomes valid when I am unable to make decisions or speak for myself. If any part of this form cannot be legally followed, I ask that all other parts of this form be followed. I also revoke any health care advance directives I have made before.
________________________________ __________________
Signature Social Security Number
Address
__________________ _____________________
Phone Date
WITNESS STATEMENT
I, the witness, declare that the person who signed or acknowledged this form (hereafter "person") is personally known to me, that he/she signed or acknowledged this form in my presence, and that he/she appears to be of sound mind and under no duress, fraud or undue influence.
I also declare that I am over 18 years of age and am NOT:
The individual appointed as (agent/proxy/surrogate/patient advocate/ representative) by this document or his/her successor,
The person's health care provider including owner or operator of a health, long-term care, or other residential or community care facility serving the person,
An employee of the person's health care provider,
Financially responsible for the person's health care,
An employee of a life or health insurance provider for the person,
Related to the person by blood, marriage, or adoption, and,
To the best of my knowledge, a creditor of the person or entitled to any part of his/her estate under a will or codicil, by operation of law.
Signature of witness number one
Printed name of Witness
__________________________________________ ___________
Address Phone
Signature of witness number two
Printed name of witness
__________________________________________ ___________
Address Phone
