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Living Will Declaration
2022-2023 Jacksonville Senior Services DirectoryTM Declaration made this _____ day of ______________ , ________. I, __________________(name), willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do hereby declare: If at any time I should have a terminal condition and if my attending physician and one other physician have determined that there can be no recovery from such a condition, and that my death is imminent: (Check one or both boxes below) ❏ I direct that life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure necessary to provide me with comfort, care, or to alleviate pain. ❏ I request that my Designated Healthcare Surrogate, ______________________(name), make
decisions on my behalf concerning the withholding of life-prolonging procedures. (Attach Healthcare Surrogate Designation.) (Check only one of the boxes below)
❏ I want nutrition and hydration (including food and water administered through tubes) to be
❏ I do not want nutrition and hydration (including food and water administered through tubes) to be withheld or withdrawn, even when it would only serve to artificially prolong the process of dying.
In the absence of my ability to give directions regarding the use of such life-prolonging procedures, it is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment, and to accept the consequences of such refusal. If I have been diagnosed as pregnant and this diagnosis is known to my physician, this declaration shall have no force or effect during the course of my pregnancy. I understand the full meaning of this declaration, and I am emotionally and mentally competent to make this declaration. Printed Name:____________________________________ Signature:___________________________ Witness Statement: The declarant is personally known to me, and I believe him/her to be of sound mind. Witness:_________________________________________ Witness:____________________________ *Note: A copy of this form should be given to your physician and the surrogate. The surrogate cannot sign as a witness. Only one witness can be a spouse or blood relative.
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2022 - 2023 Jacksonville Senior Services DirectoryTM
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withheld or withdrawn when it would only serve to artificially prolong the process of dying.
