Vermont Living Will Template
This Living Will is designed to be in compliance with the Vermont Patient's Bill of Rights Act. It allows you to guide and direct your medical treatment in advance in the event that you are unable to communicate your wishes. Ensure the following document accurately reflects your decisions and conforms with Vermont state law.
Personal Information
- Full Name: ___________________________________
- Date of Birth: ________________________________
- Address: ______________________________________
- City: _________________________________________
- State: Vermont
- Zip Code: ____________________________________
Living Will Declarations
I, ___________________________, being of sound mind, intentionally and voluntarily declare my wish that my dying shall not be artificially prolonged under the circumstances set forth below. I understand that this may apply if I am in any of the following conditions:
- A terminal condition where the application of life-sustaining treatment would only serve to artificially prolong the process of dying;
- In a permanent unconscious condition that is irreversible, in which I am completely unaware of myself and my surroundings;
- In a condition where I am expected to die without the use of life-sustaining treatment;
- Or in any other conditions specified by the laws of Vermont.
Should I be in any state mentioned, I request the following treatments and decisions:
- Life-sustaining treatment: _____________________________________________________________
- Do not resuscitate (DNR) orders: ________________________________________________________
- Artificial nutrition (feeding tubes) desires: _____________________________________________
- Pain relief preferences even if they hasten death: ________________________________________
Designation of Health Care Agent
In the event that I am incapable of making my own healthcare decisions, I designate the following individual as my Health Care Agent:
- Name: ________________________________________________
- Relationship: _________________________________________
- Phone Number: ________________________________________
- Address: _____________________________________________
This Health Care Agent shall have the authority to make all health care decisions on my behalf, including decisions about life-sustaining treatments, in accordance with what I have stated in this living will or as they believe I would have wanted.
Signature
I understand the contents of this document and the effect of this declaration to withhold or withdraw life-sustaining treatment. My signature below affirms that I am of sound mind and fully understand my right to determine the course of my medical treatment.
Date: ___________________________
Signature: ________________________
State of Vermont, County of __________________:
This document was signed in my presence by _______________________________ (name of declarant), who is personally known to me or proved to me on the basis of satisfactory evidence. This living will is signed voluntarily as the declarant's own free act and deed.
Date: ___________________________
Witness Signature: ___________________________
Printed Name: _______________________________
Address: ____________________________________