Print and Complete a Living Will form (PDF file)
A Living Will is a document that allows you to establish, in advance, the type of medical care you would want to receive if you were to become permanently unconscious, or if you were to become terminally ill and unable to tell your physician or family what kind of life-sustaining treatments you want to receive.
A Living Will is used only in situations where you are unable to tell your physician what kind of health care services you want to receive. Before your Living Will would go into effect, you either must be:
- Terminally ill (that means two physicians have determined that you have no reasonable chance of recovery) and unable to tell your physician your wishes regarding health care services;
- Permanently unconscious. To be considered permanently unconscious, two physicians (one of whom must be a medical specialist in an appropriate field) must decide that you have no reasonable possibility of regaining consciousness.
Regardless of your condition, if you were able to speak and tell your physician what you want to do about life-prolonging treatments, if you were able to speak and tell your physician what you want to do about life-prolonging treatments, then the Living Will wouldn't be used - your physician would just talk directly with you about your wishes. A Living Will is used by the physician only if you are unable to tell him or her what you want done.
- A Living Will gives your physician the authority to withhold all life-sustaining treatment and permit you to die naturally and take no action to postpone your death, providing you with only that care necessary to make you comfortable to relieve your pain. This may include writing a DNR Order or withdrawing life-sustaining treatment such as CPR.
- Such "comfort care" also may include removing nutrition and hydration (food and water) that is administered through feeding tubes or intravenously. If you wish to give your physician this authority if you become permanently unconscious, there is a space on the Living Will form that you must initial. If you want nutrition and hydration to be continued, regardless of the circumstances, don't initial this space.
- A Living will may include the option of making an anatomical gift (organ donation) upon death.
- A Living Will can be honored only if your attending physician and others know about it. It is important to let your physician and your family and friends know that you have a Living Will before you become ill. After all, a Living Will can't be enforced if people don't know that it exists. In fact, it is a good idea for you to give your attending physician a copy of your Living Will. It also is important to give copies to family and friends so that, if necessary, they can advise your physician that you have a Living Will. In addition, it is important that you notify a health care facility that you have a Living Will when you are admitted as a patient. Please note: You do not have to go to court to put your Living Will into effect.
- Once the decision to withhold life-sustaining treatment is made, your physician must make a reasonable effort to notify the person or persons you designate in your Living Will or your closest family member.
- The law allows your family members to challenge a physician's determination that you have a terminal illness or that you are in a permanently unconscious state. This challenge is limited in nature and may be made only by your closest relatives. The law does not, however, allow your family members to challenge your own legally-documented decision not to be resuscitated.
- If you have both a Living Will and a Health Care Power of Attorney (a Health Care Power of Attorney lets you appoint someone to make health care decisions for you if you become unable to express your wishes), the physician must comply with the wishes you state in your Living Will. In other words, your Living Will takes precedence over your Health Care Power of Attorney. There is a space on the Living Will form that you may check to let your physician and family and friends know that you have a Health Care Power of Attorney.
- You can revoke your Living Will at any time. You can do this by simply telling your physician and family that you have changed your mind and wish to revoke your Living Will. It is a good idea to ask anyone who has a copy of the document to return it to you.
How to fill out the Living Will form:
You should use this form to let your physician and your family know what kind of life-sustaining treatments you want to receive if you become terminally ill or permanently unconscious and unable to express your wishes.
- Read over all information carefully. Definitions are included as part of the form.
- On the first two lines of the form, print your full name and birth date.
- On the fourth page of the form, written in bold type face under Special Instructions is the statement that will give your physician permission to withhold food and fluids in the event you are permanently unconscious. If you want to give your physician permission to withhold food and water in this situation, then you must place your initials on the line indicated in number 3.
- The next section of the form (immediately below the Special Instructions) provides space for you to list the names, addresses and phone numbers of the contacts (usually family members and close friends) that you want your physician to notify when the Living Will goes into effect. Remember, the Living Will goes into effect only when you are terminally ill or permanently unconscious and you cannot express your own wishes about the health care you receive.
- Following the "list contacts" is a space to check whether or not you have completed a Health Care Power of Attorney. Immediately below this space is where you date and sign the form. Remember, the Living Will is not considered valid or effective unless you do one of the following:
First Option - Date and sign the Living Will in the presence of two witnesses, who also must sign and include their addresses and indicate the date of their signatures.
Second Option - Date and sign the Living Will in the presence of a notary public and have the Living Will notarized on the appropriate space provided on the form.
The following people may not serve as a witness to your Living Will:
Anyone related to you by blood, marriage or adoption (this includes your husband or wife and your children);
Your attending physician;
If you are in a nursing home, the administrator of the nursing home.
- Once you have filled out the Living Will and either signed it in the presence of witnesses or in the presence of a notary public, then it is a good idea to give a copy to your personal physician about any family members you have listed in the Living Will. In Ohio, people are allowed (but not required) to register their Living Wills with the county recorder. Formally registering a Living Will helps make certain that a copy will be available when it is needed. However, it is important to keep in mind that a registered Living Will form becomes a public record.
Date Updated: 19-FEB-2007