Minnesota Living Will Declaration
This Living Will is designed following the statutes of the State of Minnesota, particularly in alignment with the Minnesota Health Care Directive Act. It allows you, the declarant, to outline your wishes regarding your medical treatment should you become unable to express your preferences due to illness or incapacity.
Please complete the following information:
Full Name: ________________________________________
Date of Birth: ________________________________________
State of Residence: Minnesota
Address: __________________________________________
This document serves as a declaration of my desires concerning medical treatments or life-sustaining measures when I am unable to decide or communicate for myself due to incapacity or critical illness. I appoint the following individual as my health care agent to make medical decisions on my behalf if I am found to be unable to communicate my wishes directly:
Health Care Agent Name: __________________________________________
Relationship: __________________________________________
Contact Number: __________________________________________
Alternate Health Care Agent Name: (in case the primary agent is unavailable) __________________________________________
Relationship: __________________________________________
Contact Number: __________________________________________
In the event that I am incapacitated and unable to communicate, it is my wish:
- To receive all treatments and interventions necessary for the relief of pain or discomfort, even if such treatments may extend my life or hasten my death.
- To not receive treatments that would only serve to artificially prolong the dying process if I am diagnosed with a terminal condition that a reasonable degree of medical certainty is irreversible or incurable.
- To be allowed to die naturally and to refuse any life-sustaining treatment including, but not limited to, artificial nutrition and hydration, if it is determined that my condition is irreversible and will result in death within a relatively short time.
I understand that I can revoke or modify this declaration at any time.
Signature: _______________________________ Date: __________________
Witness Information:
To ensure the validity of this Living Will, it must be signed in the presence of two witness, neither of whom is a health care provider, an employee of a health care provider, the appointed health care agent, or any person who would have a claim against any portion of the declarant’s estate upon death.
Witness 1 Name: __________________________________________
Signature: _______________________________ Date: __________________
Witness 2 Name: __________________________________________
Signature: _______________________________ Date: __________________
Notary (if applicable)
In some cases, having your Living Will notarized may add an additional level of legal certainty. This is optional and based on personal preference.
Notary Public’s Name: __________________________________________
Signature: _______________________________ Date: __________________
The foregoing instrument was acknowledged before me this _____ day of ____________, 20____, by (name of declarant) ____________________________, who is personally known to me or who has produced ____________________________ as identification.