New York Living Will

New York Living Will

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[PRINT YOUR NAME]

I, ___________________________________, being of sound mind, make this statement as a directive to be followed if I become permanently unable to participate in decisions regarding my medical care. These instructions reflect my firm and settled commitment to decline medical treatment under the circumstances indicated below:

I direct my attending physician to withhold or withdraw treatment that merely prolongs my dying, if I should be in an incurable or irreversible mental or physical condition with no reasonable expectation of recovery.

These instructions apply if I am (a) in a terminal condition; (b) permanently unconscious; or (c) if I am minimally conscious but have irreversible brain damage and will never regain the ability to make decisions and express my wishes.

I direct that my treatment be limited to measures to keep me comfortable and to relieve pain, including any pain that might occur by withholding or withdrawing treatment.

You may make changes in any of these directions, or add changes to conform them to your personal wishes. (CROSS OUT BELOW ANY STATEMENTS WITH WHICH YOU DO NOT AGREE:)

While I understand that I am not legally required to be specific about future treatments if I am in the condition(s) described above, I feel especially strongly about the following forms of treatment:

I do not want cardiac resuscitation.

I do not want mechanical respiration.

I do not want artificial nutrition and hydration.

I do not want antibiotics.

I do want maximum pain relief, even if it may hasten my death.

Personal Instructions (Optional):

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Other directions:

These directions express my legal right to refuse treatment, under the law of New York. I intend my instructions to be carried out, unless I have rescinded them in a new writing or by clearly indicating that I have changed my mind.

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Signature

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Date

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Address

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City, State, Zip

STATEMENT OF WITNESSES

I declare that the person who signed this document is personally known to me and appears to be of sound mind and acting of his or her own free will. He or she signed (or asked another to sign for him or her) this document in my presence.

Witness #1:

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Signature of Witness #1

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Date

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Printed Name of Witness #1

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Address

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City, State, Zip

Witness #2: 

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Signature of Witness #2

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Date

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Printed Name of Witness #2

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Address

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City, State, Zip