This North Carolina Living Will is a legal document that outlines your wishes regarding medical treatment in the event you are unable to express these wishes yourself. It is crafted in accordance with the North Carolina Advance Directive for a Natural Death Act.
Personal Information
Name: _________________________________________
Date of Birth: _________________________________
Address: _______________________________________
City: ________________ State: NC Zip: ___________
Phone Number: __________________________________
Declaration
I, __________________________ [Your Name], resident of North Carolina, hereby declare my desires and instructions for medical treatment, in case I am unable to communicate my healthcare decisions.
Life-Prolonging Measures
Should I be in a condition where my death is imminent or I am in a persistent vegetative state from which there is no reasonable expectation of recovery, I direct the following:
- ____ I wish to receive life-prolonging measures that could extend my life, regardless of my condition.
- ____ I do not wish to receive life-prolonging measures if they only serve to artificially prolong the process of dying or if I have no reasonable chance of recovery.
Additional Directives
If I am unable to make my own healthcare decisions and if there are conditions other than those mentioned above, I direct the following to be considered:
- ____ Artificial nutrition and hydration (tube feeding)
- ____ Administration of pain relief, even if it may hasten my death
- ____ Do not resuscitate orders (DNR)
Designation of Health Care Agent
If necessary, I designate the following individual as my health care agent to make health care decisions for me in accordance with this living will:
Name of Health Care Agent: _______________________________
Relationship: _____________________________________________
Phone Number: ____________________________________________
Signatures
This document is executed this _____ day of _______________, 20____ by:
______________________________________
[Your Signature]
State of North Carolina )
_______________________ ) ss:
County of _______________ )
This document was acknowledged before me on __________ (date) by __________________________ (name of principal).
______________________________________
Signature of Notary Public
My commission expires: ______________
This living will is designed to be consistent with North Carolina law, but it may require additional provisions to comply with other state laws if applicable. Before signing, it is recommended to consult with a lawyer to ensure that all aspects of your wishes are legally protected and properly documented.