The living will below was derived from an article by Glen C. Griffin, MD, editor-in-chief of SENIOR PATIENT medical journal, featured in the September 1990 issue. The result of many editings and advice from many colleagues, he allows use of the thoughts and ideas contained therein and encourages everyone to prepare a living will and durable power of attorney soon. (Make sure to check your state requirements. In some states, you can't create a custom living will and will have to use an unchangeable one that's written by legislature. A link for a simple and more abbreviated living will is available at the bottom.)

I, ______________________________________________, residing at __________________________________ _______________________________, being of sound mind, willfully and voluntarily malke this Declaration:

(1) If the situation occurs that I am in a vegetative state or coma from an incurable disease process or injury (as determined by two physicians approved by my wife or designated successor attorney-in-fact), I desire and direct that life-sustaining procedures and means be withheld or withdrawn, including assisted respiratory ventilation and/or artificially administered fluids or nutrition (intravenous, gastric, jejunal, or other tube feedings), and that I be permitted to die naturally.

(2) If I should develop severe mental impairment to the degree that I am totally unable to perform activities of daily living or at least to recognize and meaningfully communicate with my family and others (as determined by two physicians approved by my wife or designated successor attorney-in-fact), I do not want intensive or prolonged hospitalizations, major surgery, artificially administered fluids or nutrition (intravenous, gastric jejunal, or other tube feedings), blood transfusions, or assisted ventilation.

(3) If the circumstance occurs that I am in a state of near-death, but a good possibility exists of recovery to a purposeful situation (such as my being able to write or otherwise communicate helpful thoughts and information to my family and others), then I do not restrict my physicians from exercising their skills with prudence, wisdom, and restraint.
     However, I do not desire extreme measures such as a heart transplant or the implantation of an artificial heart (other than the use of a temporary bypass pump during surgery). And, if the state of near-death is part of a terminal cancer or other progressively incurable disease process or injury, then I desire that measures be directed at comfort, rather than to delay the moment of death.

(4) Furthermore, if I am in a vegetative state or coma from an incurable disease process or injury, or in a state of near-death with a progressively incurable disease or injury, or if I have developed severe mental impairment to the degree that I am totally unable to perform activities of daily living or at least to recognize and meaningfully communicate with my family and others (as determined by two physicians approved by my wife or designated successor attorney-in-fact), and if my heart or lungs cease to function, I do not want to be brought back to life with medications or with electrical or mechanical resuscitation or ventilation, or even with ordinary cardiopulmonary resuscitation.

(5) In any of these circumstances, it is my desire to be made comfortable with medications that are used to control pain, knowing that such medications may unintentionally hasten death. However, medications should not be used with the intention of causing death.

(6) It is my desire that the costs of my terminal care be kept to a minimum. Therefore, unless there are compelling reasons to the contrary, I would prefer to spend my last days at home rather than in a hospital or other expensive medical facility - unless being at home would be an unreasonable burden on my family.

I am legally competent to make this Declaration, and I understand its full import.

Witness my hand and seal, this ______________day of ______________________, 19______.

                                _________________________________(SEAL)

UNDER THE PENALTIES OF PERJURY, we state that this Declaration was signed by ____________________________________________ in the presence of the undersigned, who at his request, in his presence, and in the presence of each other, have hereunto signed our names and witnessed this ___________day of ______________________, 19_______, and DECLARE:
The Declarant is personally known to me, and I believe the Declarant to be of sound mind. I did not sign the Declarant's signature to this Declaration. Based upon information and belief, I am not related to the Declarant by blood or marriage, a creditor of the Declarant, entitled to any portion of the estate of the Declarant under any existing testamentary instrument of the Declarant, financially or otherwise responsible for the Declarant's medical care, or an employee of any such person or institution.

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