Virginia Living Will
This Virginia Living Will is made in accordance with the Virginia Health Care Decisions Act. It allows you to outline your preferences for medical treatment in the event you are unable to communicate your wishes directly.
Please complete the following information to ensure this living will reflects your decisions accurately.
Personal Information Section
Personal Information
Name: ________________________________________
Date of Birth: _______________________________
Address: _____________________________________
City: ________________________________________
State: Virginia
Zip Code: ____________________________________
Directive Section
Health Care Directive
I, __________________________ (the "Principal"), being of sound mind, hereby direct my health care providers to follow my instructions as outlined in this document.
In the event that I am incapable of making my own health care decisions, including but not limited to being in a state of permanent unconsciousness or terminal condition as determined by two independent physicians, my directives are as follows:
- Life-Sustaining Treatment:
I wish to receive / refuse life-sustaining treatment that could extend my life, including artificial nutrition and hydration.
Choose one: ___ Receive ___ Refuse
- Pain Management and Comfort:
I expect my health care providers to prioritize pain management and comfort care, even if it may shorten my life.
- Artificial Nutrition and Hydration:
I wish to receive / refuse artificial nutrition and hydration if I can no longer take food or water by mouth.
Choose one: ___ Receive ___ Refuse
- Other Directives:
Please specify any other health care instructions or conditions not otherwise covered above:
__________________________________________________________
__________________________________________________________
Designation of Agent Section
Designation of Health Care Agent
If I am unable to communicate my health care wishes, I designate the following individual as my health care agent to make decisions on my behalf:
Name: _____________________________________
Relationship: _____________________________
Address: ___________________________________
Phone Number: _____________________________
This living will is made voluntarily and without any undue influence.
Signature
I affirm that the information provided in this Virginia Living Will is accurate to the best of my knowledge. I understand the consequences of this directive.
Principal's Signature: _______________________________ Date: ________________
Witness Signature: __________________________________ Date: ________________
Printed Name of Witness: _____________________________
A witness to this Virginia Living Will must not be related to the principal by blood, marriage, or adoption, should not stand to benefit from the principal's estate, and should not be directly involved in the principal's medical care.