Rhode Island Living Will
This Living Will is designed in accordance with the Rhode Island Rights of the Terminally Ill Act. It serves as a declaration of the desires of the undersigned regarding health care decisions in the event that they can no longer communicate their wishes directly.
Part 1: Information of the Declarant
Full Name: ______________________________________________________
Date of Birth: ______________________
Address: ________________________________________________________
City: ___________________________ State: Rhode Island Zip: ___________
Telephone Number: _______________________________
Part 2: Declaration
I, _________________________, being of sound mind and not under duress, fraud, or undue influence, hereby declare that, if at any time I become unable to communicate my healthcare wishes due to any physical or mental condition, I direct the following:
- Life-Prolonging Procedures:
In the event that I am in a terminal condition, a permanent unconscious condition, or in an end-stage condition, where the application of life-prolonging procedures would only serve to artificially prolong the dying process, I request that such procedures be withheld or withdrawn. My preference is to allow natural death to occur.
- Artificial Nutrition and Hydration:
Except as specifically indicated by my attending physician as necessary for my comfort or alleviation of pain, I request that artificial nutrition and hydration be withheld or withdrawn if I am in the conditions described above.
- Pain Relief:
I request that I be given medication or other measures to alleviate pain or discomfort, even if these measures hasten my death, as long as they are administered in compliance with accepted medical standards.
- Other Instructions:
________________________________________________________________
________________________________________________________________
Part 3: Designation of Health Care Agent (Optional)
If I am unable to communicate my healthcare decisions, I designate the following individual as my health care agent:
Name: ___________________________________________________________
Relationship: _________________________
Address: ________________________________________________________
City: ___________________________ State: ___________ Zip: ___________
Telephone Number: _______________________________
In the event that my primary agent is unable or unwilling to serve, I designate the following individual as my alternate health care agent:
Name: ___________________________________________________________
Relationship: _________________________
Address: ________________________________________________________
City: ___________________________ State: ___________ Zip: ___________
Telephone Number: _______________________________
Part 4: Signature
This living will is effective upon my signature and remains in force until revoked.
Signature: _______________________________ Date: _________________
Witness: __________________________________ Date: _________________
I declare that the person signing this living will is personally known to me, that he/she signed or acknowledged this living will in my presence, and that he/she appears to be of sound mind and under no duress, fraud, or undue influence.
Part 5: Notarization (Optional)
This living will was notarized on _______________ at ___________________________.
Notary Public: ______________________________________________________
Commission expires: ________________________________________________