New Mexico Living Will Template
This Living Will is made in accordance with the New Mexico Uniform Health-Care Decisions Act. It is a legal document that outlines your wishes regarding medical treatment if you become unable to communicate those wishes yourself.
Part 1: Personal Information
Full Name: _______________________________
Date of Birth: ___________________________
Address: __________________________________
City: ______________________ State: NM Zip Code: _________
Phone Number: ____________________________
Part 2: Health Care Directives
In the event that I become incapacitated and am unable to express my preferences personally, I direct my health care providers to follow the instructions outlined in this Living Will.
Life-Sustaining Treatment:
- If I am in a terminal condition, I do / do not want my life to be prolonged by life-sustaining treatments. This includes, but is not limited to, mechanical ventilation, tube feeding, and CPR.
- If I am in a state of permanent unconsciousness, I do / do not want life-sustaining treatments to be provided or continued.
- In the event of a condition that is not terminal or does not involve permanent unconsciousness, but I am unable to communicate my wishes, the following are my instructions: ___________________________________________________________________.
Pain Relief: Even if the treatments needed to relieve my pain could hasten my death, I do / do not want to receive them, as long as they offer the chance of obtaining relief.
Part 3: Designation of Health Care Agent
If I am unable to make health care decisions for myself, I designate the following individual as my health care agent:
Name: _______________________________
Relationship to me: ____________________
Phone Number: _________________________
Address: ______________________________________________________
In the event my primary agent is unable, unwilling, or unavailable to act on my behalf, I designate the following individual as an alternate agent:
Name: _______________________________
Relationship to me: ____________________
Phone Number: _________________________
Address: ______________________________________________________
Part 4: Organ and Tissue Donation
I do / do not wish to donate my organs and tissues at the time of my death. If I do wish to make an organ and tissue donation, my specific wishes are as follows:
- Any needed organs or tissues
- Only the following organs or tissues: ____________________
Part 5: Signature
This Living Will becomes effective immediately upon my incapacity to make health care decisions. This document revokes any prior Living Wills I have made.
Date: ___________________________
Signature: ________________________
State of New Mexico )
County of ___________ )
On this day, before me personally appeared _______________________ (name of principal), to me known to be the individual described in and who executed the foregoing instrument, and acknowledged that (s)he executed the same as his/her free act and deed.
Date: ___________________________
Notary Public: ___________________
My Commission Expires: ___________