Pennsylvania Living Will Form

NOTES ABOUT THE USE OF THIS FORM

 

If you decide to use this form or create your own advance health care directive, you should consult with your physician and your attorney to make sure that your wishes are clearly expressed and comply with the law.

 

If you decide to use this form but disagree with any of its statements, you may cross out those statements. You may add comments to this form or use your own form to help your physician or health care agent decide your medical care.

 

If you are a woman and diagnosed as being pregnant at the time a health care decision would otherwise be made pursuant to this form, the laws of this Commonwealth prohibit implementation of that decision if it directs that life-sustaining treatment, including nutrition and hydration, be withheld or withdrawn from you, unless your attending physician and an obstetrician who have examined you certify in your medical record that the life-sustaining treatment:

 

(1)        will not maintain you in such a way as to permit the continuing development and live birth of the unborn child;

(2)        will be physically harmful to you; or

(3)        will cause pain to you that cannot be alleviated by medication.

 

A physician is not required to perform a pregnancy test on you unless the physician has reason to believe that you may be pregnant.

 

Pennsylvania law protects your health care providers from any legal liability for following in good faith your wishes as expressed in the form. It does not otherwise change professional standards or excuse negligence in the way your wishes are carried out. If you have any questions about the law, consult an attorney for guidance.

 

This form and explanation is not intended to take the place of specific legal or medical advice for which you should rely upon your own attorney and physician.

 

HEALTH CARE TREATMENT INSTRUCTIONS

IN THE EVENT OF END-STAGE MEDICAL CONDITION

OR PERMANENT UNCONSCIOUSNESS

 

The following health care treatment instructions exercise my right to make my own health care decisions. These instructions are intended to provide clear and convincing evidence of my wishes to be followed when I lack the capacity to understand, make or communicate my treatment decisions:

 

IF I HAVE AN END-STAGE MEDICAL CONDITION (WHICH WILL RESULT IN MY DEATH, DESPITE THE INTRODUCTION OR CONTINUATION OF MEDICAL TREATMENT) OR AM PERMANENTLY UNCONSCIOUS SUCH AS AN IRREVERSIBLE COMA OR AN IRREVERSIBLE VEGETATIVE STATE AND THERE IS NO REALISTIC HOPE OF SIGNIFICANT RECOVERY, ALL OF THE FOLLOWING APPLY (CROSS OUT ANY TREATMENT INSTRUCTIONS WITH WHICH YOU DO NOT AGREE):

 

1. I direct that I be given health care treatment to relieve pain or provide comfort even if such treatment might shorten my life, suppress my appetite or my breathing, or be habit forming.
2. I direct that all life prolonging procedures be withheld or withdrawn.
3. I specifically do not want any of the following as life prolonging procedures:

 

(If you wish to receive any of these treatments, write "I do want" after the treatment)

 

heart-lung resuscitation (CPR)  _____________________________________

mechanical ventilator (breathing machine)  ____________________________

dialysis (kidney machine)  _________________________________________

surgery  ________________________________________________________

chemotherapy ___________________________________________________

radiation treatment _______________________________________________

antibiotics  _____________________________________________________

 

Please indicate whether you want nutrition (food) or hydration (water) medically supplied by a tube into your nose, stomach, intestine, arteries, or veins if you have an end-stage medical condition or are permanently unconscious and there is no realistic hope of significant recovery.

 

(Initial only one statement.)

 

TUBE FEEDINGS

_____ I want tube feedings to be given

OR

NO TUBE FEEDINGS

_____ I do not want tube feedings to be given.

HEALTH CARE AGENT'S USE OF INSTRUCTIONS

 

(Initial only one statement.)

_____ My health care agent must follow these instructions.

OR

_____ These instructions are only guidance.

 

My health care agent shall have final say and may override any of my instructions. (Indicate any exceptions)

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

 

If I did not appoint a health care agent, these instructions shall be followed.

 

LEGAL PROTECTION

 

Pennsylvania law protects my health care providers from any legal liability for their good faith actions in following my wishes as expressed in this form. On behalf of myself, my executors and heirs, I further hold my health care providers harmless and indemnify them against any claim for their good faith actions in following my treatment instructions.

 

ORGAN DONATION (INITIAL ONE OPTION ONLY.)

 

_____ I consent to donate my organs and tissues at the time of my death for the purpose of transplant, medical study or education. (Insert any limitations you desire on donation of specific organs or tissues or uses for donation of organs and tissues.)

 

 OR

 

_____ I do not consent to donate my organs or tissues at the time of my death.

 

Having carefully read this document, I have signed it this ____ day of _______________, 20___, revoking all previous health care powers of attorney and health care treatment instructions.

 

Signed:                               

(SIGN FULL NAME HERE FOR HEALTH CARE TREATMENT INSTRUCTIONS)

 

Witness                                    

 

Witness                                    

 

 

Two witnesses at least 18 years of age are required by Pennsylvania law and should witness your signature in each other's presence. A person who signs this document on behalf of and at the direction of a principal may not be a witness. (It is preferable if the witnesses are not your heirs, nor your creditors, nor employed by any of your health care providers.)

 

NOTARIZATION (OPTIONAL)

 

(Notarization of document is not required by Pennsylvania law, but if the document is both witnessed and notarized, it is more likely to be honored by the laws of some other states.)

 

On this this ____ day of _______________, 20___, before me personally appeared the aforesaid declarant and principal, to me known to be the person described in and who executed the foregoing instrument and acknowledged that he/she executed the same as his/her free act and deed.

 

IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal in the County of ______________, State of ______________, the day and year first above written.

 

 

                                          

Notary Public

 

 

My Commission Expires: _____________________