LIVING WILL AND ADVANCE HEALTHCARE DIRECTIVE

DECLARATION

I, [FULL LEGAL NAME], residing at [ADDRESS], born on [DATE OF BIRTH], with Social Security Number [SSN] (optional), telephone number [PHONE NUMBER], and email address [EMAIL ADDRESS], being of sound mind and at least eighteen (18) years of age, willfully and voluntarily make this declaration to express my wishes regarding medical treatment and care in the event I am unable to communicate my healthcare decisions directly.

This document shall serve as my Living Will and Advance Healthcare Directive in accordance with the laws of the state of [STATE]. I intend for this document to be legally binding and enforceable, and I ask that my family, physicians, healthcare providers, and all those concerned with my care honor my wishes as expressed herein.

ARTICLE I: HEALTHCARE AGENT DESIGNATION

Section 1.1: Appointment of Healthcare Agent

I hereby appoint the following individual as my primary healthcare agent (also known as my healthcare proxy or attorney-in-fact for healthcare decisions):

Primary Healthcare Agent:

• Name: [AGENT NAME]
• Address: [AGENT ADDRESS]
• Telephone: [AGENT PHONE]
• Email: [AGENT EMAIL]
• Relationship to me: [RELATIONSHIP]

Section 1.2: Alternate Healthcare Agents

In the event that my primary healthcare agent is unable, unwilling, or unavailable to act as my healthcare agent, I appoint the following individuals, in the order listed, to serve as my alternate healthcare agents:

First Alternate Healthcare Agent:

• Name: [FIRST ALTERNATE NAME]
• Address: [FIRST ALTERNATE ADDRESS]
• Telephone: [FIRST ALTERNATE PHONE]
• Email: [FIRST ALTERNATE EMAIL]
• Relationship to me: [RELATIONSHIP]

Second Alternate Healthcare Agent:

• Name: [SECOND ALTERNATE NAME]
• Address: [SECOND ALTERNATE ADDRESS]
• Telephone: [SECOND ALTERNATE PHONE]
• Email: [SECOND ALTERNATE EMAIL]
• Relationship to me: [RELATIONSHIP]

Section 1.3: Powers and Authority of Healthcare Agent

I grant my healthcare agent full power and authority to make healthcare decisions for me if I am unable to make or communicate decisions for myself. This includes, but is not limited to, the power to:

1. Consent to, refuse, or withdraw any type of medical care, treatment, surgical procedure, diagnostic procedure, medication, and the use of mechanical or other procedures affecting any portion of my body;

2. Make decisions regarding artificial nutrition and hydration, cardiopulmonary resuscitation, mechanical ventilation, dialysis, blood transfusions, antibiotics, pain management, and all other forms of medical treatment;

3. Request, receive, review, and have access to any information, verbal or written, regarding my physical or mental health, including but not limited to medical and hospital records, and to consent to the disclosure of this information as necessary;

4. Employ and discharge healthcare providers including physicians, psychiatrists, dentists, nurses, therapists, and any other persons who may be involved with my healthcare;

5. Authorize my admission to or discharge from any hospital, nursing home, residential care, assisted living or similar facility or service;

6. Take any lawful actions necessary to execute the powers granted herein, including the granting of releases of liability to medical providers;

7. Apply for public benefits, such as Medicare and Medicaid, for me and to appeal any denial or termination of benefits;

8. Make decisions regarding participation in research protocols related to my medical condition(s); and

9. Authorize or decline to authorize visitation as my agent deems appropriate, with the exception of the following individuals who shall be allowed to visit me: [NAMES OF INDIVIDUALS WHO MUST BE ALLOWED TO VISIT, IF ANY].

Section 1.4: Limitations on Healthcare Agent's Authority

Notwithstanding the powers granted above, my healthcare agent is subject to the following limitations:

1. My healthcare agent must act in good faith and in accordance with my best interests, taking into account my personal values and the preferences expressed in this document;

2. My healthcare agent may not authorize any of the following, unless I have expressly indicated otherwise in this document or in a separate writing: a. Psychosurgery; b. Sterilization; c. Abortion; d. Voluntary admission to any mental health facility; or e. Experimental treatments or procedures not approved by an Institutional Review Board.

3. [ANY ADDITIONAL LIMITATIONS ON AGENT'S AUTHORITY]

Section 1.5: HIPAA Authorization

I intend for my healthcare agent to be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information and other medical records. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. 1320d and 45 CFR 160-164, and the regulations promulgated thereunder.

I authorize any physician, healthcare professional, dentist, health plan, hospital, clinic, laboratory, pharmacy, or other covered healthcare provider, any insurance company, and the Medical Information Bureau, Inc., or other healthcare clearinghouse that has provided treatment or services to me, or that has paid for or is seeking payment from me for such services, to give, disclose, and release to my healthcare agent, without restriction, all of my individually identifiable health information and medical records regarding any past, present, or future medical or mental health condition.

This authorization shall supersede any prior agreement that I may have made with my healthcare providers to restrict access to or disclosure of my individually identifiable health information. The individually identifiable health information and other medical records given, disclosed, or released to my healthcare agent may be subject to redisclosure by my healthcare agent and may no longer be protected by HIPAA.

ARTICLE II: LIFE-SUSTAINING TREATMENT PREFERENCES

Section 2.1: General Statement of Preferences

If I am unable to make or communicate decisions regarding my healthcare, and I have a terminal condition or am in a persistent vegetative state, or my physician and another consulting physician have determined that I am in a condition from which there is no reasonable probability of recovery and which is likely to lead to my death within a relatively short time without the application of life-sustaining procedures, I direct that the following preferences be followed with respect to life-sustaining treatment:

Section 2.2: Cardiopulmonary Resuscitation (CPR)

In the event my heart stops beating or I stop breathing, I direct that:

[SELECT ONE OPTION]

• I DO want cardiopulmonary resuscitation (CPR) attempted in all circumstances.
• I DO NOT want cardiopulmonary resuscitation (CPR) attempted if my condition is terminal or irreversible and death is imminent.
• I DO NOT want cardiopulmonary resuscitation (CPR) attempted under any circumstances.
• I want CPR attempted ONLY in the following circumstances: [SPECIFY CIRCUMSTANCES]

Section 2.3: Mechanical Ventilation

Regarding the use of a mechanical ventilator (breathing machine) to support or replace my breathing function, I direct that:

[SELECT ONE OPTION]

• I DO want mechanical ventilation used in all circumstances.
• I DO want a trial period of mechanical ventilation, but if after [SPECIFY TIME PERIOD, e.g., "14 days"] there is no significant improvement in my condition, I direct that mechanical ventilation be withdrawn.
• I DO NOT want mechanical ventilation if my condition is terminal or irreversible and death is imminent.
• I DO NOT want mechanical ventilation under any circumstances.
• I want mechanical ventilation ONLY in the following circumstances: [SPECIFY CIRCUMSTANCES]

Section 2.4: Artificial Nutrition and Hydration

Regarding the provision of nutrition and hydration through artificial means such as feeding tubes or intravenous lines when I am unable to take food or water by mouth, I direct that:

[SELECT ONE OPTION]

• I DO want artificial nutrition and hydration provided in all circumstances.
• I DO want a trial period of artificial nutrition and hydration, but if after [SPECIFY TIME PERIOD, e.g., "30 days"] there is no significant improvement in my condition, I direct that artificial nutrition and hydration be withdrawn.
• I DO NOT want artificial nutrition and hydration if my condition is terminal or irreversible and death is imminent.
• I DO NOT want artificial nutrition and hydration under any circumstances.
• I want artificial nutrition and hydration ONLY in the following circumstances: [SPECIFY CIRCUMSTANCES]

Section 2.5: Dialysis

Regarding the use of dialysis to filter waste from my blood if my kidneys stop functioning properly, I direct that:

[SELECT ONE OPTION]

• I DO want dialysis used in all circumstances.
• I DO want a trial period of dialysis, but if after [SPECIFY TIME PERIOD, e.g., "30 days"] there is no significant improvement in my condition, I direct that dialysis be discontinued.
• I DO NOT want dialysis if my condition is terminal or irreversible and death is imminent.
• I DO NOT want dialysis under any circumstances.
• I want dialysis ONLY in the following circumstances: [SPECIFY CIRCUMSTANCES]

Section 2.6: Antibiotics and Medication

Regarding the use of antibiotics and other medications to treat infections or manage symptoms, I direct that:

[SELECT ONE OPTION]

• I DO want antibiotics and other medications administered in all circumstances.
• I DO want antibiotics and other medications for the purpose of treating infections, but not if my condition is terminal or irreversible and death is imminent.
• I DO NOT want antibiotics under any circumstances, but I DO want medications for pain relief and comfort care.
• I want antibiotics and other medications ONLY in the following circumstances: [SPECIFY CIRCUMSTANCES]

Section 2.7: Pain Management and Comfort Care

Regarding pain management and comfort care (palliative care), I direct that:

1. I wish to receive adequate pain medication to ensure my comfort, even if such medication might hasten my death.

2. I wish to receive palliative care focused on relieving pain and suffering, managing symptoms, and maximizing quality of life rather than extending it when cure is no longer possible.

3. I wish to die at [SELECT ONE: "home," "hospice facility," "hospital," or "OTHER LOCATION"] if possible and if it does not place an undue burden on my family or caregivers.

4. Additional instructions regarding pain management and comfort care: [ADDITIONAL INSTRUCTIONS]

ARTICLE III: SPECIFIC MEDICAL SCENARIOS

Section 3.1: Persistent Vegetative State

If I am diagnosed as being in a persistent vegetative state or permanent unconscious condition with no reasonable hope of recovery, as determined by my attending physician and at least one other qualified physician, I direct that:

1. Life-sustaining treatment, including artificial nutrition and hydration, be withheld or withdrawn.

2. I be allowed to die naturally, with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain.

3. Additional instructions: [ADDITIONAL INSTRUCTIONS]

Section 3.2: Terminal Illness

If I am diagnosed with a terminal illness or condition and death is expected within six months, as determined by my attending physician and at least one other qualified physician, I direct that:

1. Life-sustaining treatment that would serve only to artificially prolong the process of my dying be withheld or withdrawn.

2. I be allowed to die naturally, with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain.

3. Additional instructions: [ADDITIONAL INSTRUCTIONS]

Section 3.3: End-Stage Condition

If I am diagnosed with an end-stage condition that has caused severe and permanent deterioration, indicated by incompetency and complete physical dependency for which treatment of the irreversible condition would be medically ineffective, as determined by my attending physician and at least one other qualified physician, I direct that:

1. Life-sustaining treatment, including artificial nutrition and hydration, be withheld or withdrawn.

2. I be allowed to die naturally, with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain.

3. Additional instructions: [ADDITIONAL INSTRUCTIONS]

Section 3.4: Dementia Provisions

If I am diagnosed with severe dementia or similar cognitive impairment, such that I am unable to recognize my family or loved ones, unable to communicate verbally, and am dependent on others for most or all of my care, I direct that:

1. No life-sustaining procedures, including artificial nutrition and hydration, be initiated or continued when they would serve only to prolong my existence.

2. I not be given antibiotics for infections such as pneumonia or other life-threatening infections if the primary purpose is to prolong my life rather than provide comfort.

3. I be allowed to die naturally, with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain.

4. If I appear to be experiencing distress or discomfort, I wish to receive appropriate medication to relieve such distress or discomfort, even if such medication might hasten my death.

5. Additional instructions: [ADDITIONAL INSTRUCTIONS]

ARTICLE IV: ORGAN AND TISSUE DONATION

Section 4.1: Organ Donation Wishes

[SELECT ONE OPTION]

• I DO wish to be an organ and tissue donor. I authorize the donation of any organs, tissues, or parts of my body for transplantation, therapy, research, or education.
• I DO wish to be an organ and tissue donor, but ONLY for the following organs or tissues: [SPECIFY ORGANS/TISSUES]
• I DO wish to be an organ and tissue donor, but with the following restrictions: [SPECIFY RESTRICTIONS]
• I DO NOT wish to be an organ or tissue donor.

Section 4.2: Body Donation for Medical Research

[SELECT ONE OPTION]

• I DO wish to donate my body for medical research or educational purposes.
• I DO wish to donate my body for medical research or educational purposes, but with the following restrictions: [SPECIFY RESTRICTIONS]
• I DO NOT wish to donate my body for medical research or educational purposes.

If I have elected to donate my body for medical research or educational purposes, I understand that this may preclude organ donation for transplantation purposes. In case of conflict, my preference is: [SELECT ONE: "organ donation for transplantation" or "whole body donation for research/education"].

ARTICLE V: FUNERAL AND BURIAL ARRANGEMENTS

Section 5.1: Funeral Preferences

My preferences regarding funeral services are as follows:

1. I wish to have a [SELECT ONE: "traditional funeral service," "memorial service," "celebration of life," "no service," or "OTHER PREFERENCE"].

2. I prefer that the service be held at [LOCATION PREFERENCE].

3. I would like the following religious or spiritual elements to be included: [RELIGIOUS/SPIRITUAL ELEMENTS].

4. Other specific requests regarding my funeral service: [SPECIFIC REQUESTS].

Section 5.2: Disposition of Remains

Regarding the disposition of my remains, I direct the following:

[SELECT ONE OPTION]

• I wish to be buried at [CEMETERY NAME AND LOCATION].
• I wish to be cremated, and my ashes disposed of as follows: [SPECIFY DISPOSITION OF ASHES].
• I wish for my body to be donated to medical science as specified in Section 4.2.
• Other disposition: [SPECIFY OTHER DISPOSITION].

Section 5.3: Memorial Contributions

In lieu of flowers, I request that memorial contributions be made to:

1. [CHARITY/ORGANIZATION NAME AND ADDRESS]
2. [CHARITY/ORGANIZATION NAME AND ADDRESS]
3. [CHARITY/ORGANIZATION NAME AND ADDRESS]

ARTICLE VI: ADDITIONAL CONSIDERATIONS

Section 6.1: Religious or Spiritual Preferences

My religious or spiritual beliefs that should guide my medical care and end-of-life decisions are as follows:

1. Religious/spiritual affiliation: [RELIGIOUS/SPIRITUAL AFFILIATION]

2. Religious/spiritual practices that are important to me: [IMPORTANT PRACTICES]

3. I would like to receive the following religious/spiritual support at the end of life: [RELIGIOUS/SPIRITUAL SUPPORT]

4. I would like the following religious/spiritual leader to be contacted:

   • Name: [RELIGIOUS/SPIRITUAL LEADER NAME]
   • Organization: [ORGANIZATION NAME]
   • Contact information: [CONTACT INFORMATION]

Section 6.2: Personal Values Statement

The following values and beliefs are important to me and should guide the interpretation of this document and any healthcare decisions made on my behalf:

1. [PERSONAL VALUE #1]
2. [PERSONAL VALUE #2]
3. [PERSONAL VALUE #3]
4. [ADDITIONAL VALUES AS NEEDED]

When making healthcare decisions on my behalf, I want my healthcare agent and healthcare providers to consider the following quality of life factors that are important to me:

1. [QUALITY OF LIFE FACTOR #1]
2. [QUALITY OF LIFE FACTOR #2]
3. [QUALITY OF LIFE FACTOR #3]
4. [ADDITIONAL FACTORS AS NEEDED]

Section 6.3: Pregnancy Provisions

[FOR WOMEN OF CHILDBEARING AGE] If I am pregnant at the time this directive becomes effective, I direct that:

[SELECT ONE OPTION]

• All life-sustaining treatment be provided to me, regardless of my condition, until my child can be safely delivered.
• Life-sustaining treatment be provided to me only if my physician believes there is a reasonable possibility that my child will develop to the point of live birth with continued application of life-sustaining treatment.
• The same treatment preferences expressed elsewhere in this document be followed, regardless of my pregnancy status, to the extent permitted by law.
• The following specific instructions be followed regarding my care if I am pregnant: [SPECIFIC INSTRUCTIONS]

I understand that in some states, a Living Will or similar directive may not be honored during pregnancy regardless of my wishes.

Section 6.4: Digital Assets and Social Media

Regarding my digital assets and social media accounts during my incapacity, I direct that:

1. My healthcare agent shall have the authority to access, modify, control, archive, transfer, and delete my digital assets, including but not limited to my email accounts, social media accounts, digital music, digital photographs, digital videos, gaming accounts, software licenses, cloud storage accounts, domain registrations, web hosting accounts, cryptocurrency, and other online accounts.

2. My healthcare agent may post appropriate notifications regarding my condition on my social media accounts and may respond to messages sent to me through these platforms.

3. I specifically authorize my healthcare agent to take the following actions with respect to my digital assets and social media accounts: [SPECIFIC AUTHORIZATIONS]

4. I specifically prohibit my healthcare agent from taking the following actions with respect to my digital assets and social media accounts: [SPECIFIC PROHIBITIONS]

5. Access information for important digital accounts:

   • Password manager: [PASSWORD MANAGER INFORMATION]
   • Important account #1: [ACCOUNT INFORMATION]
   • Important account #2: [ACCOUNT INFORMATION]
   • [ADDITIONAL ACCOUNTS AS NEEDED]

ARTICLE VII: LEGAL PROVISIONS

Section 7.1: Revocation

I understand that I may revoke this Living Will and Advance Healthcare Directive at any time by:

1. Physically destroying this document or directing someone else to destroy it in my presence;
2. Signing and dating a written revocation;
3. Verbally expressing my intent to revoke this document in the presence of a witness who is at least 18 years of age, who understands the nature of the revocation, and who signs and dates a writing confirming my expression to revoke; or
4. Executing a new Living Will and Advance Healthcare Directive that is materially different from this one.

I understand that if I revoke this document, I should notify my healthcare agent, my healthcare providers, and anyone else who has a copy of this document.

Section 7.2: Severability

If any provision of this Living Will and Advance Healthcare Directive is held to be invalid, illegal, unenforceable, or inapplicable to any circumstance by a court of competent jurisdiction in the state of [STATE], such provision shall be deemed modified to the minimum extent necessary to make it valid, legal, and enforceable while preserving its intent, or if such modification is not possible, such provision shall be severed from this document. The invalidity, illegality, unenforceability, or inapplicability of any provision shall not affect any other provisions or applications of this document, which shall continue in full force and effect without the invalid, illegal, unenforceable, or inapplicable provision.

Section 7.3: Governing Law

This Living Will and Advance Healthcare Directive shall be governed by and construed in accordance with the laws of the state of [STATE], without giving effect to any choice of law or conflict of law provisions.

Section 7.4: Definitions

For purposes of this document, the following terms shall have the meanings set forth below:

1. "Life-sustaining treatment" means any medical procedure, treatment, intervention, or other measure that, when administered to a patient, will serve to prolong the process of dying or to maintain the patient in a condition of permanent unconsciousness.

2. "Terminal condition" means an incurable and irreversible condition that, without the administration of life-sustaining treatment, will, in the opinion of the attending physician and at least one other consulting physician, result in death within a relatively short time.

3. "Persistent vegetative state" means a permanent and irreversible condition of unconsciousness in which there is: (a) the absence of voluntary action or cognitive behavior of any kind, and (b) an inability to communicate or interact purposefully with the environment.

4. "End-stage condition" means an irreversible condition that is caused by injury, disease, or illness which has resulted in progressively severe and permanent deterioration, and which, to a reasonable degree of medical probability, treatment of the condition would be ineffective.

5. "Healthcare agent" means an individual designated in a healthcare power of attorney or similar document to make healthcare decisions on behalf of the person executing the document.

6. "Artificial nutrition and hydration" means the provision of nutrients or fluids by a tube inserted into a vein, under the skin, or in the stomach or intestines.

Section 7.5: Conflicting Provisions

If any provision of this Living Will and Advance Healthcare Directive conflicts with any provision of a Durable Power of Attorney for Healthcare that I have previously executed and not revoked, the provision of the document executed most recently shall control.

ARTICLE VIII: DISTRIBUTION AND ACCESS

Section 8.1: Distribution List

I direct that copies of this Living Will and Advance Healthcare Directive be provided to the following individuals and institutions:

1. My primary healthcare agent: [PRIMARY AGENT NAME]
2. My alternate healthcare agents: [ALTERNATE AGENT NAMES]
3. My primary care physician: [PHYSICIAN NAME AND CONTACT INFORMATION]
4. My specialist physicians: [SPECIALIST NAMES AND CONTACT INFORMATION]
5. The hospital(s) where I typically receive care: [HOSPITAL NAMES]
6. My immediate family members: [FAMILY MEMBER NAMES]
7. My attorney: [ATTORNEY NAME AND CONTACT INFORMATION]
8. [OTHER RECIPIENTS AS APPROPRIATE]

Section 8.2: Electronic Access Provisions

Electronic copies of this document are stored in the following locations, and may be accessed as follows:

1. My personal computer: [LOCATION AND ACCESS INFORMATION]
2. Cloud storage: [SERVICE NAME AND ACCESS INFORMATION]
3. Electronic registry: [REGISTRY NAME AND ACCESS INFORMATION]
4. With my attorney: [ATTORNEY NAME AND CONTACT INFORMATION]
5. [OTHER ELECTRONIC STORAGE LOCATIONS]

In case of emergency, my healthcare agent or healthcare providers may access electronic copies of this document by contacting the individuals listed above or by using the following emergency access information: [EMERGENCY ACCESS INFORMATION]

ARTICLE IX: INTEGRATION WITH OTHER DOCUMENTS

Section 9.1: Coordination with Other Advance Directives

This Living Will and Advance Healthcare Directive is intended to work in conjunction with the following other advance directives that I have executed:

1. Durable Power of Attorney for Healthcare, dated [DATE]
2. POLST (Physician Orders for Life-Sustaining Treatment) or similar form, dated [DATE]
3. DNR (Do Not Resuscitate) Order, dated [DATE]
4. [OTHER RELEVANT DOCUMENTS]

In the event of any conflict between this document and any other advance directive I have executed, the document executed most recently shall control, unless otherwise specified herein.

Section 9.2: Consistency with Estate Plan

This Living Will and Advance Healthcare Directive is intended to be consistent with my overall estate plan, including my Last Will and Testament dated [DATE] and any Trust Agreements I have established. My healthcare agent should consult with the executor of my estate and/or the trustee of any trust I have established if questions arise regarding the coordination of my healthcare decisions with my overall estate plan.

EXECUTION

IN WITNESS WHEREOF, I sign this Living Will and Advance Healthcare Directive voluntarily, while of sound mind and under no constraint or undue influence.

Dated: ________________________

Signature: ________________________

Print Name: [FULL LEGAL NAME]

WITNESS ATTESTATION

The declarant is personally known to me and I believe the declarant to be of sound mind and under no constraint or undue influence. I am at least eighteen (18) years of age and am not related to the declarant by blood, marriage, or adoption, and am not entitled to any portion of the declarant's estate under any existing will or codicil or by operation of law. I am not the declarant's attending physician, the healthcare agent, or an employee of the attending physician or healthcare facility in which the declarant is a patient.

Witness #1:

Signature: ________________________

Print Name: ________________________

Address: ________________________

Date: ________________________

Witness #2:

Signature: ________________________

Print Name: ________________________

Address: ________________________

Date: ________________________

NOTARY ACKNOWLEDGMENT

State of ________________________

County of ________________________

On ________________________, before me, ________________________, a Notary Public, personally appeared [FULL LEGAL NAME], who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her authorized capacity, and that by his/her signature on the instrument the person executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of ________________________ that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

Signature: ________________________ (Seal)

My commission expires: ________________________