Louisiana Living Will
This Living Will document is prepared in accordance with the Louisiana Declarations Concerning Life-Sustaining Procedures Act, allowing individuals to dictate their preferences for medical treatment in the event they become unable to communicate their wishes directly.
Personal Information
- Full Name: ___________________________
- Date of Birth: ________________________
- Address: _____________________________
- City: _______________________________
- State: Louisiana
- ZIP Code: ___________________________
Declaration
I, ________________ [name], a resident of ________________ [city], Louisiana, being of sound mind, intentionally and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below. This declaration reflects my firm and settled commitment to decline life-sustaining treatment that serves only to prolong the process of dying.
Directions for Health Care
- If I am diagnosed in writing to be in a terminal and irreversible condition, I direct that life-sustained treatment be withheld or withdrawn, except to the extent necessary to maintain comfort.
- I wish to designate the following individual as my health care agent to make medical decisions on my behalf if I am ever unable to speak for myself:
Name: ___________________________
Relationship: _____________________
Contact Number: __________________
- In the event that I am unable to designate a health care agent, I wish for my attending physician to follow the directions stated herein regarding the initiation, continuation, withholding, or withdrawal of life-sustaining treatment.
- I give the following additional instructions, if any, regarding my care: ___________________________________________________________
Signature
I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration.
Date: ___________________
Signature: ___________________________
Print Name: ___________________________
Witness Declaration
This declaration was signed in my presence by the declarant, who is personally known to me or has provided satisfactory evidence of identity. To the best of my knowledge, the declarant is of sound mind and under no duress, fraud, or undue influence.
- Witness 1:
Date: ___________________
Signature: ___________________________
Print Name: ___________________________
Address: _____________________________
- Witness 2:
Date: ___________________
Signature: ___________________________
Print Name: ___________________________
Address: _____________________________
Notarization (Optional)
This document was acknowledged before me on ________ [date] by __________________ [name of declarant].
Date: _______________________
Notary Public: ___________________________
My commission expires: ___________________