|
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.
(enter 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.
|
|
|
|
|
Legal Disclaimer Privacy Policy |