California Living Will Template
This Living Will is designed to comply with the requirements of the California Natural Death Act. It serves as a declaration of the undersigned's desires regarding their health care treatment in the event that they are unable to make such decisions for themselves due to incapacity.
Part I: Information of the Declarant
Full Name: ___________________________________________________________
Date of Birth: ______________________
Address: ____________________________________________________________
City: ______________________ State: CA Zip Code: _________________
Primary Phone: ______________________ Secondary Phone: _______________
Part II: Directive Regarding Life-Sustaining Treatment
I, ___________________________________, being of sound mind, hereby instruct my health care provider and designated agent(s), as follows:
In the case where I am in a terminal condition, I direct that life-sustaining treatment be withheld or withdrawn. Life-sustaining treatment can be defined as any medical procedure, machine, or medication that sustains, restores, or supplants a vital function, but does not cure my medical condition and only prolongs the dying process.
In the case where I am in a persistent vegetative state, with no reasonable expectation of regaining consciousness, I direct the same as above.
If I am unable to make these decisions for myself and am diagnosed with a condition that is not terminal but requires life-sustaining treatment to continue my existence, I elect to (choose one):
- a) Receive all life-sustaining treatment that may prolong my life.
- b) Receive only treatments that are necessary for my comfort and to relieve pain, even if such treatments may hasten my death.
- c) Do not receive life-sustaining treatments, except those necessary for comfort and pain relief.
Part III: Signature and Witnesses
Signature of Declarant: _______________________________ Date: ________________
This document requires witness signatures to be legally binding. Witnesses should not be related to the declarant by blood or marriage, entitled to any part of the declarant’s estate, or be directly financially responsible for the declarant’s medical care.
Witness 1 Signature: _______________________________ Date: ________________
Witness 1 Printed Name: ___________________________________________________
Witness 2 Signature: _______________________________ Date: ________________
Witness 2 Printed Name: ___________________________________________________
Part IV: Organ Donation (Optional)
If I am eligible and have not otherwise specified my desires regarding organ and tissue donation in another document or registry, I would like to provide for organ and tissue donation as follows:
___ I do not wish to donate any organs or tissues at the time of my death.
___ I wish to donate only the following organs or tissues: ____________________________________
___ I wish to donate any needed organs or tissues.