Kansas Living Will Template
This Kansas Living Will is a legal document that outlines the principal's healthcare preferences in the event that they are no longer able to communicate or make decisions on their own due to a terminal illness or incapacitating condition. This document is created under the Kansas Living Will Act, allowing individuals to specify their desires regarding life-sustaining treatment and other healthcare decisions.
Principal Information
Full Name: _______________________________________________
Date of Birth: ____________________________________________
Address: __________________________________________________
City: ________________________ State: KS Zip: ______________
Healthcare Directives
In the event that I am determined to be in a terminal condition and unable to communicate my healthcare wishes, I direct that:
- My healthcare providers shall prolong my life through medically appropriate treatment, except in the cases where I have specified otherwise in this document.
- No life-sustaining treatment shall be administered if it only serves to artificially prolong the dying process or if I am determined to be in a persistent vegetative state with no reasonable chance of recovery.
- My preference regarding the following life-sustaining treatments: (initial one)
____ I wish to receive all available treatments, including artificially provided nutrition and hydration.
____ I do not wish to receive the following treatments: ___________________________________________________.
- Additional wishes or instructions, if any:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Healthcare Proxy
I designate the following individual as my healthcare proxy to make medical decisions for me if I am incapable of making such decisions:
Name: _______________________________________________
Relationship: ______________________________________
Phone Number: ______________________________________
In the event that my healthcare proxy is unavailable, unwilling, or unable to make decisions for me, I designate the following alternate:
Name: _______________________________________________
Relationship: ______________________________________
Phone Number: ______________________________________
Signature
By signing below, I affirm that I am of sound mind and I fully understand the contents of this Kansas Living Will. I also understand that I can revoke this document at any time.
Signature: _______________________________ Date: ____________________
Witness Signature: _____________________________ Date: ________________
Witness Signature: _____________________________ Date: ________________
Notary
(If required) This document was acknowledged before me on ________________ (date) by _____________________________ (name of principal).
Notary Public Signature: ___________________________________
Commission expires: _______________________________________