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Sample Hospital Forms


Each of the fifty states have some law regarding the abilityof patients to make decisions about their medical care before the need fortreatment arises through the use of advance directives. The great majority ofstates allow for patients to draft living wills that set forth the type andduration of medical care that they wish to receive should they become unable tocommunicate those wishes on their own.

Although the law in each state will vary as to what can beincluded in a living will, the following sample can provide a general overviewof what one may look like, and what information may be included. Of course, before assuming that this sample will besufficient for your purposes, you should check the law in your jurisdiction orhave an attorney review your advance directives. In some states,however, an unapproved document may have some persuasive effect.

To my family, doctors, hospitals, surgeons, medical careproviders, and all others concerned with my care:

I,______________________________, being of sound mind and rationalthought, willfully and voluntarily make this declaration to befollowed if I become incompetent or incapacitated to the extentthat I am unable to communicate my wishes, desires and preferenceson my own.

This declaration reflects my firm, informed, and settled commitmentto refuse life-sustaining medical care and treatment under thecircumstances that are indicated below.

This declaration and the following directions are an expression ofmy legal right to refuse medical care and treatment. I expect andtrust the above-mentioned parties to regard themselves as legallyand morally bound to act in accordance with my wishes, desires, andpreferences. The above-mentioned parties should therefore be freefrom any legal liabilities for having followed this declaration andthe directions that it contains.

This Living WillDeclaration expresses my firm wishes, desires, and preferences and the factthat I may have executed a form specified by the law of the State of _____________,may not be used a limiting or contradicting this Living Will Declaration, whichis an expression of both my common law and constitutional rights.

I declare that theperson who signed or acknowledged this document is personally known to me, thathe/she signed or acknowledged this Living Will Declaration in my presence, andthat he/she appears to be of sound mind and under no duress, fraud, or undueinfluence.

I declare that theperson who signed or acknowledged this document is personally known to me, thathe/she signed or acknowledged this Living Will Declaration in my presence, andthat he/she appears to be of sound mind and under no duress, fraud, or undue influence.

Note: For manypeople, taking away food and water from a dying person seems especially cruelbecause they may feel as though the person is starving or dehydrating to death.However, you have a right to make your specific wishes known on the subject. Itis advisable, however, to be particularly clear on those issues so that thereis no room for your loved ones to debate. In addition, they will likely feelless burdened by guilt if they are certain they are following your specificwishes not to be artificially fed or hydrated.