LIVING WILL DECLARATION
Example Form from Pennsylvania Act 169 of 2006
I, _________________________, being of sound mind, willfully and voluntarily make
this declaration to be followed if I become incompetent. This declaration reflects my firm and
settled commitment to refuse life-sustaining treatment under the circumstances indicated below.
I direct my attending physician to withhold or withdraw life-sustaining treatment that
serves only to prolong the process of my dying, if I should be in a terminal condition or in a state
of permanent unconsciousness.
I direct that treatment be limited to measures to keep me comfortable and to relieve pain,
including any pain that might occur by withholding or withdrawing life-sustaining treatment.
In addition, if I am in the condition described above, I feel especially strong about the
following forms of treatment:
I ( ) do ( ) do not want cardiac resuscitation.
I ( ) do ( ) do not want mechanical respiration.
I ( ) do ( ) do not want tube feeding or any other artificial or invasive form of nutrition
(food) or hydration (water).
I ( ) do ( ) do not want blood or blood products.
I ( ) do ( ) do not want any form of surgery or invasive diagnostic tests.
I ( ) do ( ) do not want kidney dialysis.
I ( ) do ( ) do not want antibiotics.
I realize that if I do not specifically indicate my preference regarding any of the forms of
treatment listed above, I may receive that form of treatment.
Other instructions:
I ( ) do ( ) do not want to designate another person as my surrogate to make medical
treatment decisions for me if I should be incompetent and in a terminal condition or in a state of
permanent unconsciousness.
Name and address of surrogate (if applicable):
Name and address of substitute surrogate (if surrogate designated above is unable to
serve):
