Fill and Sign the Living Will Form 481369855

Living Will Directive (KRS 311.625) My wishes regarding life-prolonging treatment and artificially provi ded nutrition and hydration to be provided to me if I no longer have decisional capacity, have a terminal condition, or become permanently unconscious have been indicated by checking and initiali ng the appropriate lines below. By checking and initialing the appropriate lines, I specifically: _____ Designate _________________________________________ as my health care surrogate(s) to make health care decisions for me in accordance with this directive whe n I no longer have decisional capacity. If _________________________________________ refuses or is not able to act for me, I designate _________________________________________ as my health care surrogate(s). Any prior designation is revoked. If I do not designate a surrogate, the followi ng are my directions to my attending physician. If I have designated a surrogat e, my surrogate shall comply with my wishes as indicated below: _____ Direct that treatment be withheld or withdrawn, and that I be permit ted to die naturally with only the administration of medication or the performance of any medical treatment deemed necessary to alleviate pain. _____ DO NOT authorize that life-prolonging treatment be withheld or withdrawn. _____ Authorize the withholding or withdrawal of artificially provided food, wate r, or other artificially provided nourishment or fluids. _____ DO NOT authorize the withholding or withdrawal of artificially provi ded food, water, or other artificially provided nourishment or fluids. _____ Authorize my surrogate, designated above, to withhold or withdraw artifici ally provided nourishment or fluids, or other treatment if the surrogate determines that withholding or withdrawing is in my best interest; but I do not mandate that withholding or withdrawing. _____ Authorize the giving of all or any part of my body upon death for any purpose specified in Section 10 of this Act. _____ DO NOT authorize the giving of all or any part of my body upon death. In the absence of my ability to give directions regarding the use of life -prolonging treatment and artificially provided nutrition and hydration, it is my intention that t his directive shall be honored by my attending physician, my family, and any surrogate designated pursuant to this directive as the final expression of my legal right to refuse medical or surgical treatment and I accept the consequences of the refusal. If I have been diagnosed as pregnant and that diagnosis is known to my attending physician, this directive shall have no force or effect during the course of my pregnancy. I understand the full import of this directive and I am emotionally and mentally competent to make this directive. Signed this day of _____________________, 20 ______________________________________________________________________________ Signature of the grantor. _________________________________________ Printed name of the grantor. _________________________________________ Address of the grantor. In our joint presence, the grantor, who is of sound mind and eighteen (18) years of age, or older, voluntarily dated and signed this writing or directed it to be dated and signed for the grantor. ______________________________________________________________________________ Signature of the witness. _________________________________________ Printed name of the witness. _________________________________________ Address of the witness. ______________________________________________________________________________ Signature of the witness. _________________________________________ Printed name of the witness. _________________________________________ Address of the witness. OR STATE OF KENTUCKY _________________________________________ County Before me, the undersigned authority, came the grantor who is of sound mind and eighteen (18) years of age, or older, and acknowledged that he voluntarily dated and signed this writing or directed it to be signed and dated as above. Done thi s day of ______________________ 20 _________________________________________________________ Signature of Notary Public or other officer. Date commission expires: ___________________________ Execution of this document restricts withholding and withdrawing of some medical procedures. Consult Kentucky Revised Statutes or your attorney.