Oregon Living Will
This document serves as a Living Will, designed to express the desires concerning medical treatment of _____________________ (hereinafter referred to as "the Principal"), in accordance with the Oregon Advance Directive Act.
Principal Information:
- Full Name: ___________________________________
- Date of Birth: _______________________________
- Address: ______________________________________
- City: __________________ State: OR Zip: ________
By this document, I, the Principal, indicate my desires regarding the provision, withholding, or withdrawal of life-sustaining procedures and artificially administered nutrition and hydration if I am in a state of permanent unconsciousness or am otherwise unable to make my own medical decisions.
Selections Regarding Life-Sustaining Treatment:
If I, the Principal, am in a state of permanent unconsciousness or any other condition in which I am unable to communicate my wishes and am unlikely to regain the ability to make medical decisions, it is my intention through this Living Will to direct my attending physician as follows:
- ____ If I am in a state of permanent unconsciousness, I do/do not (circle one) want life-sustaining treatment to be provided. This includes, but is not limited to, mechanical ventilation, cardiopulmonary resuscitation (CPR), and other procedures that extend my life, excluding the provision of nutrition and hydration by artificial means.
- ____ If I am unable to communicate and have a terminal illness, I do/do not (circle one) want treatments that would only prolong the process of dying even if I am not unconscious.
- ____ I do/do not (circle one) want to receive nutrition and hydration by artificial means if I am unable to take food or water by mouth and my condition is irreversible and terminal.
Additional Instructions:
You may add any specific preferences or instructions concerning your health care here:
_________________________________________________________
_________________________________________________________
Appointment of Health Care Representative:
I hereby designate the following individual as my health care representative to make medical decisions for me if I am unable to do so:
- Name: __________________________________________
- Relationship to Principal: ________________________
- Primary Phone: __________________________________
- Alternate Phone: ________________________________
In the event the above-named representative is unable or unwilling to serve, I designate the following individual as my alternate health care representative:
- Name: __________________________________________
- Relationship to Principal: ________________________
- Primary Phone: __________________________________
- Alternate Phone: ________________________________
Signature of Principal:
I understand the nature and purpose of this document and am mentally competent to make this Living Will. I understand that I can revoke this document at any time when I am capable of making my own health care decisions.
Date: ____________ Signature: _______________________________
Witness Declaration:
This Living Will was signed in my presence. The Principal appeared to be of sound mind and free of duress, fraud, or undue influence.
- Name of Witness: __________________________________
- Signature of Witness: ______________________________
- Date: ____________________________________________