This Living Will template is designed in accordance with the District of Columbia Health-Care Decisions Act. It allows you to outline your preferences for medical treatment should you become unable to make decisions for yourself.
Personal Information
Full Name: __________________________________________________
Date of Birth: _______________________________________________
Address: _____________________________________________________
City: ___________________________ State: DC Zip Code: ___________
Phone Number: ________________________________________________
Instructions for Health Care
This section allows you to detail your wishes regarding medical treatment in situations where you cannot communicate your decisions.
I, _______________ (your full name), being of sound mind, make the following statements regarding my medical care preferences should the time come when I can no longer make decisions for myself due to incapacitation:
- End-of-Life Treatment
If I am at an end stage of life or have been diagnosed with a terminal illness, and recovery is not expected, my wishes are as follows:
______________________________________________________________
______________________________________________________________
- Life-Sustaining Measures
In the case of a temporary condition where life-sustaining measures could help recover with a reasonable quality of life, my preferences are:
______________________________________________________________
______________________________________________________________
- Do Not Resuscitate Orders (DNR)
If my heart stops beating or if I stop breathing, my preferences on attempting resuscitation are:
______________________________________________________________
- Artificial Nutrition and Hydration
Regarding the provision of food and water through artificial means:
______________________________________________________________
- Pain Management and Comfort Care
My directives for treatments focused on relieving pain and suffering, even if they may hasten my death, are:
______________________________________________________________
Primary Health Care Proxy
If I am unable to make health care decisions for myself, I designate the following individual as my health care proxy, who is authorized to make medical decisions on my behalf:
Name: ________________________________________________________
Relationship to Me: ___________________________________________
Phone Number: ________________________________________________
Alternate Health Care Proxy
If my primary health care proxy is unable, unwilling, or unavailable to act on my behalf, I designate the following individual as my alternate health care proxy:
Name: ________________________________________________________
Relationship to Me: ___________________________________________
Phone Number: ________________________________________________
Signature
By signing below, I affirm that these are my wishes and that I understand the consequences of these directives. I am of sound mind and under no duress or undue influence in making these decisions.
Date: ________________________ Signature: ___________________________
Witness Signature
I, _______________ (witness name), declare that the person signing this document is personally known to me and appears to be of sound mind and acting willingly and without coercion. I am not the person appointed as healthcare proxy or alternate.
Date: ________________________ Signature: ___________________________