North Dakota Living Will Template
This North Dakota Living Will allows you to express your wishes regarding healthcare if you become unable to communicate them yourself. It is crafted in accordance with the North Dakota Uniform Health-Care Decisions Act.
Personal Information
Full Name: ___________________________________________________
Date of Birth: ________________________________________________
Address: _____________________________________________________
City: ________________________State: ND Zip: __________________
Phone Number: ________________________________________________
Health Care Instructions
My wishes for medical treatment and care are as follows:
- Life-Sustaining Treatment:
___ I wish to receive life-sustaining treatments, including artificial nutrition and hydration, if my life is at risk.
___ I do not wish to receive life-sustaining treatments if I have a terminal condition, am in a persistent vegetative state, or if the treatments would only prolong the process of dying.
- Pain Relief:
___ I wish to receive medication to relieve pain and suffering, even if it may indirectly shorten my life.
- Specific Treatments:
___ I consent to/refuse the following treatments (list treatments): ________________________________________
Health Care Agent
I hereby designate the following individual as my Health Care Agent to make medical decisions for me if I become incapable of making my own decisions:
Name: ________________________________________________________
Relationship: _________________________________________________
Phone Number: ________________________________________________
Alternate Agent (if primary is unable/unwilling to serve):
Name: ________________________________________________________
Relationship: _________________________________________________
Phone Number: ________________________________________________
Organ Donation
___ I wish to donate any needed organs or tissues upon my death.
___ I do not wish to donate my organs or tissues upon my death.
Specific Instructions: __________________________________________
Signature
This document is in effect as of the date signed. I understand that I can revoke it at any time.
Signature: ___________________________________ Date: _____________
Witness: ____________________________________ Date: _____________
Instructions for Completing and Using the North Dakota Living Will
- Complete the template with your personal information and health care preferences.
- Sign and date the document in the presence of a witness who is not related to you and would not inherit anything from you.
- Inform your health care providers and Health Care Agent about your living will. Provide them with copies.
- Keep the original document in a safe, accessible place.