Kentucky Living Will
This Living Will is created in accordance with the laws of the Commonwealth of Kentucky. It expresses my wishes regarding medical treatment in the event that I am unable to communicate my decisions.
Personal Information
- Name: ____________________________
- Date of Birth: _____________________
- Address: __________________________
- City: _____________________________
- State: ____________________________
- Zip Code: _________________________
Declaration
I, the undersigned, being of sound mind, willfully and voluntarily make this declaration to be followed in the event that I am unable to make my own medical decisions.
Instructions
If I am diagnosed with a terminal condition, or if I am in a persistent vegetative state, I direct that:
- Life-sustaining treatment be withheld or withdrawn.
- I be allowed to die naturally without artificial prolongation of the dying process.
If I am diagnosed with a condition that is not terminal but leaves me unable to make my own medical decisions, I wish for the following:
- Medical treatment to be provided as deemed appropriate by my healthcare provider.
- To be kept comfortable and free from pain.
Appointment of Healthcare Surrogate
If I am unable to make my own healthcare decisions, I appoint the following person as my healthcare surrogate:
- Name of Surrogate: ____________________________
- Relationship: _________________________________
- Phone Number: ________________________________
Signatures
By signing below, I affirm that I am of legal age and that this Living Will reflects my wishes regarding medical treatment.
Signature: ____________________________
Date: ________________________________
Witness 1: ____________________________
Date: ________________________________
Witness 2: ____________________________
Date: ________________________________
This document must be signed in the presence of two witnesses who are not related to you and who will not inherit from you.