Pennsylvania Living Will
This document serves as a Living Will, meant to express the wishes of the undersigned, regarding their medical treatment preferences in circumstances where they are unable to communicate their decisions due to incapacity or illness, following the specifications of the Pennsylvania Advance Directive for Health Care Act.
Part I: Information of the Declarant
Full Name: ___________________________________________________
Date of Birth: ________________________________________________
Address: _____________________________________________________
City: _______________________________ State: PA Zip: _________
Phone Number: _______________________________________________
Part II: Treatment Preferences
Please indicate your treatment preferences below. Your decisions will guide your healthcare providers in the event you are unable to communicate your wishes directly.
- Life-sustaining treatment:
- I wish to receive all available life-sustaining treatments, including artificially provided food and water, regardless of my condition.
- I do not wish to receive life-sustaining treatments if I am in a state deemed terminal or permanently unconscious, except as indicated below:
- Specific instructions concerning the conditions under which I wish to refuse or request particular types of life-sustaining treatments are as follows:
________________________________________________________________
__________________________________________________________________.
- Pain relief:
- I wish to receive treatment to relieve pain and other symptoms, even if such treatment may hasten my death, except as indicated below:
- Other wishes:
- If I am pregnant, my treatment preferences are: ___________________________________________________
- Additional instructions: _____________________________________________________________
Part III: Organ and Tissue Donation
Please indicate below if you wish to donate your organs, tissues, or both, upon death. Your decision will be honored at the time of your death, as permitted by law.
- I wish to donate the following organs/tissues: ___________________________________________
- I do not wish to make an organ or tissue donation.
Part IV: Designation of Health Care Agent
If you would like to appoint a person as your agent to make health care decisions for you when you cannot make them yourself, please provide the following information about that person:
Name: _________________________________________________________
Relationship to you: ____________________________________________
Phone Number: _________________________________________________
Alternate Phone Number: ________________________________________
Part V: Signature and Witnesses
This document will not be valid unless it is signed in the presence of two qualified witnesses or a notary public. Witnesses cannot be individuals who are financially responsible for your medical care, related to you by blood, marriage, or adoption, or beneficiaries in your will. Please sign and date below.
Signature of Declarant: __________________________ Date: ___________
Witness 1 Signature: _____________________________ Date: ___________
Witness 2 Signature: _____________________________ Date: ___________
Part VI: Professional Review
It is recommended, though not required, that you discuss your advance directive with a healthcare professional to ensure your wishes are clearly understood.
Healthcare Professional's Name: ____________________________________
Title: ___________________________________________________________
Signature: ________________________________ Date: ________________
This section is optional and may not be applicable in all circumstances.