Ohio Living Will Declaration
This Living Will Declaration is specifically tailored to comply with the statutes of the State of Ohio, formally recognizing the rights of individuals to control decisions relating to their own medical care, including the decision to have life-sustaining treatment provided, withheld, or withdrawn in instances of a terminal condition or permanent unconsciousness as defined under Ohio law.
Please complete the following information:
Full Legal Name: ___________________________________________________
Date of Birth: _____________________________________________________
Address: ___________________________________________________________
City: _________________________ State: OH Zip: _____________________
Primary Phone: ___________________________
Email: ___________________________________
In accordance with the Ohio Revised Code, Chapter 2133, known as the "Ohio Living Will Act," I hereby declare my wishes:
Should I be in a terminal condition or permanently unconscious, I direct that:
- My healthcare providers shall withhold or withdraw treatment that only prolongs the process of dying and is not necessary for my comfort or to alleviate pain.
- Nutrition and hydration, whether provided orally or by tube, are to be withheld or withdrawn if my attending physician and at least one other physician determine that I am in a permanent unconscious state or suffering from a terminal condition and that the provision of nutrition and hydration will not provide comfort or relieve pain.
- I wish to designate the following individual as my healthcare power of attorney (also known as a healthcare proxy) to make medical decisions for me if I am unable to do so myself:
Name: _______________________________________
Relationship: ________________________________
Phone: _______________________________________
Alternate Contact (optional):
Name: _______________________________________
Relationship: ________________________________
Phone: _______________________________________
- In the event that I cannot communicate my healthcare preferences, and I am in a state where there is no reasonable expectation of recovery, I desire that my healthcare team prioritize comfort care, aiming to relieve pain and suffering, and allowing natural death.
This declaration reflects my firm intention and desire concerning my medical treatment and care. I understand that I may revoke this declaration at any time.
Date: _________________
Signature: ___________________________________
Witness Statement: I declare that the person signing this document is personally known to me and appears to be of sound mind and under no duress, fraud, or undue influence. I am not the person appointed as healthcare power of attorney by this document.
Name of Witness #1: ___________________________________________________
Signature of Witness #1: ______________________________________________
Date: _________________
Name of Witness #2 (Optional): _________________________________________
Signature of Witness #2: _______________________________________________
Date: _________________
Notice: This document does not authorize the provision, withholding, or withdrawal of healthcare that would be inconsistent with generally accepted healthcare standards applicable to the healthcare provider or institution treating the patient.