New York Living Will Template
This New York Living Will Template is designed to be compliant with the New York State Health Care Proxy Law, allowing individuals to express their preferences about medical treatment in the event they are unable to communicate their decisions.
Personal Information
Full Name: _____________
Date of Birth: _____________
Address: _____________, _____________, New York, _____________
Telephone Number: _____________
Health Care Directive
I, _____________, being of sound mind, hereby direct that my health care providers and others involved in my care follow the instructions provided in this document, should I become unable to make my own health care decisions.
Life-Sustaining Treatment
In the event that I am in a terminal condition, permanently unconscious, or otherwise unable to express my preferences regarding treatment, I direct my health care providers:
- To administer treatment only if it is necessary to alleviate pain or discomfort, and not to prolong life,
- To withhold or withdraw life-sustaining measures that serve only to prolong the process of dying,
- To follow the specific directions I have provided below:
Specific Directions: _____________
Artificial Nutrition and Hydration
Regarding the provision of nutrition and hydration by artificial means, I direct the following:
- Administer neither artificial nutrition nor hydration,
- Administer artificial nutrition and hydration only as necessary to provide comfort care, or
- Administer artificial nutrition and hydration to prolong my life as long as possible.
Specific Instructions: _____________
Health Care Agent
If a health care proxy has been designated, the health care proxy’s decisions are to be honored over the instructions in this document, to the extent allowed by New York law.
Health Care Proxy’s Name: _____________
Relationship to me: _____________
Telephone Number: _____________
Signature
I understand that I can revoke this directive at any time in a manner specified by law. I am aware that unless I revoke it, this directive will remain in effect indefinitely.
Date: _____________
Signature: _____________
Witness: _____________
Date: _____________
Relationship to declarant: _____________