Missouri Living Will Declaration
This Living Will Declaration is designed to be in compliance with the Missouri Uniform Living Will Act. It allows you to express your wishes regarding medical treatment in the event you are unable to communicate these decisions yourself.
Please complete the following sections with your information to ensure your wishes are honored.
Part 1: Declaration of Principal
I, __________ [Your Full Name]__________, residing at __________ [Your Full Address, City, Missouri, Zip Code]__________, being of sound mind, willfully and voluntarily make this declaration to be followed if I become unable to participate in decisions regarding my medical care.
In accordance with the Missouri Uniform Living Will Act, I direct that my health care providers and others involved in my care provide, withhold or withdraw treatment in accordance with my directions below:
Part 2: Treatment Preferences
- LIFE-SUSTAINING TREATMENT: In the event I have a terminal condition, an end-stage condition, or am in a persistent vegetative state, and my attending physician determines that there is no reasonable prospect of my recovery to a significant quality of life:
- ______ I direct that all treatments other than those needed for my comfort care be discontinued or withheld, and my physician allow me to die as gently as possible;
- ______ I request that I be kept as comfortable as possible through the administration of pain-relieving measures, including palliative care.
- ARTIFICIAL NUTRITION AND HYDRATION: In the same circumstances as above, regarding the provision of nutrition and hydration by artificial or technological means:
- ______ I direct that such measures be withheld or withdrawn as I wish to allow natural death to occur;
- ______ I wish to receive such measures if my physician believes they could provide comfort or alleviate pain.
Part 3: Additional Directions
(Optional) Below, you may provide any additional instructions or express specific desires regarding your medical treatment that have not been addressed above:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Part 4: Declaration of Witnesses
I declare that the person signing this declaration:
- Is personally known to me;
- Has voluntarily signed this declaration in my presence;
- Appears to be of sound mind and under no duress, fraud, or undue influence;
- Has affirmed that he/she is sufficiently informed to make this declaration.
Witness 1: __________ [Witness Name]__________
Address: __________ [Witness Address]__________
Phone Number: __________ [Witness Phone Number]__________
Witness 2: __________ [Witness Name]__________
Address: __________ [Witness Address]__________
Phone Number: __________ [Witness Phone Number]__________
This document is effective upon my inability to communicate my health care decisions and it shall remain in effect until revoked.
Part 5: Signature
Signed this ______ day of _________ [month], _______ [year].
______________________
Principal's Signature
State of Missouri
County of __________
Subscribed and sworn before me this ______ day of ________ [month], _______ [year].
______________________
Notary Public
My Commission Expires: __________