Nebraska Living Will
This document serves as a Living Will, designed specifically to comply with the statutes of the state of Nebraska. It is a declaration of the undersigned's wishes regarding the use of life-sustaining treatments and artificially provided nutrition and hydration in the event they are unable to express informed consent due to incapacity.
Personal Information
Name of Declarant: ___________________________
Date of Birth: ___________________________
Address: ____________________________________
City:_____________________, State: Nebraska, Zip Code: ___________
Declaration
I, ___________________________ (Name of Declarant), being of sound mind, hereby declare my wishes in the event that I am unable to communicate my healthcare decisions due to incapacity. This living will shall guide my physician and healthcare providers in making decisions about providing, withholding, or withdrawing life-sustaining treatments and artificially provided nutrition and hydration.
Directions for Health Care
- In the event that I am in a terminal condition, I direct that my healthcare providers allow my natural death to occur. I do not want life-sustaining treatment, except for the purposes of comfort care.
- If I am in a persistent vegetative state or irreversible coma and there is no reasonable expectation of recovery, I do not want life-sustaining treatments to be used. This includes artificially provided nutrition and hydration.
- Should I be diagnosed with a serious illness from which I am expected to recover, I desire that all available treatments be used, except in the circumstances described above.
Signature
By signing this document, I affirm that I understand the nature and purpose of this declaration and that my statements reflect my wishes:
Signature of Declarant: ___________________________
Date: ___________________________
Witness Declaration
This Living Will was signed in my presence by the Declarant named above, who appears to be of sound mind and under no duress, fraud, or undue influence. I am not related to the Declarant by blood, marriage, or adoption, and to the best of my knowledge, I am not entitled to any part of the estate of the Declarant under any will or by operation of Nebraska law.
Signature of Witness #1: ___________________________
Date: ___________________________
Print Name: ___________________________
Address: __________________________________________
Signature of Witness #2: ___________________________
Date: ___________________________
Print Name: ___________________________
Address: __________________________________________