Utah Living Will Template
This Living Will is based on the requirements specified in the Utah Advance Health Care Directive Act. It is designed to express the wishes of the individual concerning medical treatment in circumstances where they are unable to communicate those wishes themselves.
Personal Information:
Full Name: ___________________________
Date of Birth: ________________________
Social Security Number: _________________
Declaration:
I, ________________ [Your Name], residing at ______________________________ [Your Address], being of sound mind, knowingly and voluntarily declare that if at any time I am unable to make or communicate my health care decisions, my wishes are as follows:
Life-Sustaining Treatment:
- In the event that I am in a persistent vegetative state, terminal condition, or irreversible coma, I do/do not want life-sustaining treatments to be provided or continued. This may include artificially provided nutrition and hydration.
- If I am in a condition where my death is imminent regardless of the use of life-sustaining treatment, I do/do not want such treatments to be provided or continued.
Artificial Nutrition and Hydration:
I do/do not want to receive artificially provided food and water if I am unable to take nourishment by mouth.
Additional Instructions:
[Insert any specific instructions or limitations regarding health care decisions not covered above.]
Your presence or participation in video or audio recorded health care deliberations is/is not authorized under the condition that such recordings will be used for health care decision-making purposes.
Designation of Health Care Agent:
I designate the following individual as my Health Care Agent to make health care decisions for me if I am unable to make those decisions myself:
Name: ___________________________
Relationship: ______________________
Address: ___________________________
Phone Number: _____________________
Alternate Health Care Agent:
If my primary Health Care Agent is unable, unwilling, or unavailable to act on my behalf, I designate the following individual as an alternate Health Care Agent:
Name: ___________________________
Relationship: ______________________
Address: ___________________________
Phone Number: _____________________
Signature:
I understand that I may revoke this Living Will at any time.
Signature: ________________________
Date: _____________________________
Witness Declaration:
This document was signed in my presence on (date) ______________ by (name of declarant) ________________________ who is personally known to me or who has provided ________________ [type of identification] as identification. The declarant appears to be of sound mind and under no duress, fraud, or undue influence.
Name of Witness: _________________________
Signature of Witness: _____________________
Date: ___________________________________
This template is a basic framework for a Utah Living Will and may need to be adjusted based on individual circumstances and preferences. It is recommended to consult with a legal professional for advice and to ensure compliance with current Utah law and any other applicable laws.