Iowa Living Will Template
This document, an Iowa Living Will, is designed to meet the requirements set forth in the Iowa Living Will Act (Iowa Code Chapter 144A). It is a legally binding document that records the wishes of an individual (hereafter known as the "Principal") regarding their medical treatment in situations where they are unable to communicate or make decisions due to a terminal condition or permanent unconsciousness.
Principal Information
- Full Name: ___________________________
- Date of Birth: ________________________
- Address: ______________________________
- City: ___________ State: Iowa Zip: _________
Living Will Declaration
I, _________________ (Principal's full name), being of sound mind and legal age, do hereby declare:
In the event that I suffer from a terminal condition or permanent unconsciousness, where my attending physician and another medical professional both conclude that there is no reasonable expectation of my recovery to a meaningful quality of life, I direct that the following treatments be withheld or withdrawn:
- Life-sustaining procedures that serve only to prolong the dying process
- Artificial nutrition and hydration
- Artificially administered respiration
- Any other medical or surgical procedures that provide no medical benefit to me and serve only to delay inevitable death
It is my intention that this living will be honored by my family, physicians, and other healthcare providers as the final expression of my legal right to refuse medical treatment, even if the cost of refusing treatment might hasten my death.
Designation of Health Care Advocate (Optional)
If I am unable to make my own health care decisions, I designate the following individual as my Health Care Advocate:
- Name: ___________________________
- Relationship: ____________________
- Phone: ___________________________
- Address: __________________________
My Health Care Advocate shall have the authority to make any health care decisions on my behalf, according to the wishes I have expressed in this document, to the extent permitted by law.
Signature
This document is signed voluntarily by me, the Principal, as my Living Will, on this___ day of _____________, 20____.
- Principal's Signature: ___________________________
- Printed Name: _________________________________
Witness Statement
We, the undersigned witnesses, declare that the Principal appears to be of sound mind and under no duress, fraud, or undue influence. We are not the designated Health Care Advocate, nor are we healthcare providers or employees of a healthcare facility where the Principal is receiving care. Additionally, we are not related to the Principal by blood, marriage, or adoption, and we do not stand to inherit any part of the Principal’s estate upon their death.
- Witness 1 Signature: ___________________________
- Printed Name: ________________________________
- Date: ________________________________________
- Witness 2 Signature: ___________________________
- Printed Name: ________________________________
- Date: ________________________________________