Advance Directive For A Natural Death Form ("Living Will") printable pdf download

ADVANCE DIRECTIVE FOR A NATURAL DEATH ("LIVING WILL")

NOTE: YOU SHOULD USE THIS DOCUMENT TO GIVE YOUR HEALTH CARE PROVIDERS

INSTRUCTIONS TO WITHHOLD OR WITHDRAW LIFE-PROLONGING MEASURES IN CERTAIN

SITUATIONS. THERE IS NO LEGAL REQUIREMENT THAT ANYONE EXECUTE A LIVING WILL.

GENERAL INSTRUCTIONS: You can use this Advance Directive ("Living Will") form to give instructions

for the future if you want your health care providers to withhold or withdraw life-prolonging measures in

certain situations. You should talk to your doctor about what these terms mean. The Living Will states

what choices you would have made for yourself if you were able to communicate. Talk to your family

members, friends, and others you trust about your choices.

Also, it is a good idea to talk with

professionals such as your doctors, clergypersons, and lawyers before you complete and sign this Living

Will.

You do not have to use this form to give those instructions, but if you create your own Advance Directive

you need to be very careful to ensure that it is consistent with North Carolina law.

This Living Will form is intended to be valid in any jurisdiction in which it is presented, but places outside

North Carolina may impose requirements that this form does not meet.

If you want to use this form, you must complete it, sign it, and have your signature witnessed by two

qualified witnesses and proved by a notary public. Follow the instructions about which choices you can

initial very carefully. Do not sign this form until two witnesses and a notary public are present to watch

you sign it. You then should consider giving a copy to your primary physician and/or a trusted relative,

and should consider filing it with the Advanced Health Care Directive Registry maintained by the North

Carolina Secretary of State:

My Desire for a Natural Death

I, ________________________, being of sound mind, desire that, as specified below, my life not be

prolonged by life-prolonging measures:

When My Directives Apply

My directions about prolonging my life shall apply IF my attending physician determines that I lack

capacity to make or communicate health care decisions and:

NOTE: YOU MAY INITIAL ANY OR ALL OF THESE CHOICES.

I have an incurable or irreversible condition that will result in my death

(Initial)

within a relatively short period of time.

I become unconscious and my health care providers determine that, to a

(Initial)

high degree of medical certainty, I will never regain my consciousness.

I suffer from advanced dementia or any other condition which results in

(Initial)

the substantial loss of my cognitive ability and my health care providers

determine that, to a high degree of medical certainty, this loss is not

reversible.

Advance Directive For A Natural Death Form ("Living Will")