Mississippi Living Will
This Mississippi Living Will template is designed to comply with the Mississippi Uniform Health-Care Decisions Act, allowing a person (known as the principal) to outline their wishes regarding healthcare and treatment in the event they are unable to communicate their decisions due to illness or incapacity.
Please fill in the blanks with the appropriate information to personalize your living will.
Principal's Information
Name: ___________________________________________________
Date of Birth: ___________________________________________
Address: _________________________________________________
City, State, ZIP: _________________________________________
Telephone Number: ________________________________________
Health Care Directive
I, ________________ (the "Principal"), being of sound mind, willfully, and voluntarily make this declaration to be followed in the event I lack the capacity to make my own health care decisions. This declaration reflects my firm and settled commitment to refuse life-sustaining treatment and artificially provided nutrition and hydration if I am in a terminal condition or in a state of permanent unconsciousness.
Life-Sustaining Treatment
In the event that I am in a terminal condition or a state of permanent unconsciousness, and where my attending physician and another consulting physician have determined that there is no reasonable expectation of my recovery to a meaningful quality of life, I direct that:
- All treatments other than those needed for my comfort or the alleviation of pain be discontinued or withheld.
- Life-sustaining treatments such as artificially or technologically supplied nutrition and hydration be withdrawn or withheld.
Designation of Health Care Proxy
I designate the following individual as my health care proxy to make medical decisions for me if I become incapable of making my own decisions:
Name: ___________________________________________________
Relationship: ____________________________________________
Telephone Number: ________________________________________
Address: _________________________________________________
In the event the above-named proxy is unable or unwilling to serve, I designate the following as an alternate proxy:
Name: ___________________________________________________
Relationship: ____________________________________________
Telephone Number: ________________________________________
Address: _________________________________________________
Signature
I understand the full import of this declaration and am emotionally and mentally competent to make this declaration.
Signature: _______________________________ Date: _____________
State of Mississippi, County of _______________
Subscribed and sworn to before me this ____ day of ___________, 20__.
Notary Public: __________________________
My commission expires: ___________________