Living Will Generator - create your Living Will online

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Step 1: Create Your Living Will

Instructions: Please read each item carefully. Review all possible choices before making a selection. When you are finished, click on the "Create My Living Will" button on the bottom of the page. * = required field

1. Enter Your Personal Information

Personal information will not be stored or distributed.

Name: First*

Middle Last*

Address*

City*

State*

(this tool was designed for NY residents, but will apply in many other states. Please enter your correct state abbreviation in the box. Click here for more information)

Zip Code*

2. Situations in which your living will applies

Check the boxes below that indicate when the living will should apply.

(*Choose all that apply))

If my doctors determine that I have a condition or illness that is incurable or
irreversible, and I am no longer able to communicate my wishes

If I am in a deep coma, persistent vegetative state, or have suffered other severe neurologic injury which my doctors feel is irreversible

If I am irreversibly demented to the point that I can no longer convey my wishes about medical care

I would like to specify other conditions in addition to or instead of the above choices

3. State your wishes about medical care

Click the option below that reflects your choice about medical treatment for the situations selected in part 2.

(*Choose one of the following)

I would like any and all potentially effective medical therapy available, including all forms of life-support treatment.

I would like all treatment available, including life-support treatment, however if the treatment is not improving my condition I request that it be stopped.

I ask to withhold (or if already started, to stop) all forms of therapy, including life-support treatment, that are not intended solely for my comfort.

I ask to withhold only certain specific life-support therapies. (click for options)

I would like to specify in my own words my wishes about desired medical therapy.

4. Artificial Nutrition and Hydration

If, in the circumstances specified in (2), you are unable to maintain adequate nourishment through eating and drinking by mouth,
select below your choice for being nourished and/or hydrated artificially :
[Click here for help with artificial nutrition and hydration]

(*choose one of the following)

I want to receive nutrition and hydration by the most effective means.

I feel strongly that I do not want certain means of artificial nutrition used (click for options).

I do not want to be fed or hydrated by any artificial means.

I would like to specify in my own words my wishes about artificial nutrition and hydration.

(*check the box below if you agree with the statement)

I request that my doctors regularly reevaluate my plan for nutrition to be sure it is meeting my needs

5. Relief of Pain and Suffering

In the circumstances you specified in part 2, what are your wishes about pain relief?

(*Choose one of the following)

I would like the best available pain relief, even if it may hasten my death.

I would like to specify in my own words my wishes about pain relief.

(*check all that apply)

I would like every attempt to be made to minimize my suffering and maximize my dignity

I ask that every attempt be made to maximize contact with my family and friends

I would like to add my own words about any other wishes I may have that I would like to convey to my family and care providers

6. Choose optional expiration or limitation

Your Living Will will remain valid indefinitely unless you set an expiration date or condition for its expiration. Setting expiration criteria is optional.

(*Choose one of the following)

I would like this living will to remain in effect indefinitely, unless I revoke it.

I would like to set an expiration date.

I would like to set circumstances under which this living will will expire.

I would like to set an expiration date and circumstances under which this living will will expire.

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