Kentucky Living Will Template
This Living Will template is designed to guide residents of Kentucky in expressing their wishes regarding medical treatment in circumstances where they are unable to communicate their decisions. It is crafted in consideration of the Kentucky Living Will Directive Act, ensuring its relevance to state-specific regulations.
Personal Information
Full Name: _____________________________________________________
Date of Birth: _______________ Social Security Number: _______________
Address: ________________________________________________________
City: ___________________ State: KY Zip Code: _______________
Living Will Declarations
I, ___________________________, being of sound mind, hereby set forth this Living Will to present my wishes concerning my medical treatment. This document shall come into effect if I am in a state that prevents me from participating in decisions regarding my medical care.
In the event that I am in a terminal condition, permanently unconscious, or otherwise unable to communicate my healthcare decisions, I direct the following:
- Life-Prolonging Treatment:
- I wish to receive all available life-prolonging treatments, including medically administered nutrition and hydration.
- I do not want any life-prolonging treatments, including medically administered nutrition and hydration.
- Power of Attorney:
I hereby designate the following individual as my attorney-in-fact for health care decisions:
Name: ___________________________________ Relationship: _____________________
Address: ________________________________________________________________
City: ___________________ State: ____ Zip Code: _______________ Phone: ________________
- Primary Physician:
I designate the following primary physician:
Name: ___________________________________
Address: ________________________________________________________________
City: ___________________ State: ____ Zip Code: _______________ Phone: ________________
Declaration Statement
I affirm that this Living Will reflects my personal wishes. I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration.
Signature: _______________________________ Date: _______________
Witnesses:
1. Witness #1 Name: ___________________________________________
Address: ______________________________________________________
City: ___________________ State: KY Zip Code: _______________
Signature: _______________________________ Date: _______________
2. Witness #2 Name: ___________________________________________
Address: ______________________________________________________
City: ___________________ State: KY Zip Code: _______________
Signature: _______________________________ Date: _______________
Note: According to Kentucky law, your Living Will must be witnessed by two individuals who are not related to you, are not your heirs, and will not benefit from your estate.