Indiana Living Will Template
This Living Will is created in accordance with Indiana state laws regarding advance directives. It outlines your wishes regarding medical treatment in the event you are unable to communicate your preferences.
Personal Information:
- Name: _______________________________
- Date of Birth: ________________________
- Address: _____________________________
- City, State, Zip: _____________________
- Phone Number: ________________________
Declaration:
I, the undersigned, being of sound mind, do hereby declare this document to be my Living Will. I understand that this document allows me to express my wishes regarding medical treatment in the event that I am unable to communicate my preferences due to a terminal condition or persistent vegetative state.
Instructions:
- If I am diagnosed with a terminal condition, I do not wish to receive life-sustaining treatment, including but not limited to:
- Mechanical ventilation
- Cardiopulmonary resuscitation (CPR)
- Artificial nutrition and hydration
- If I am in a persistent vegetative state, I do not wish to receive life-sustaining treatment.
- In all other circumstances, I wish to receive all available treatments to prolong my life.
Designation of Health Care Representative:
If I am unable to make my own health care decisions, I appoint the following individual as my health care representative:
- Name: _______________________________
- Relationship: _________________________
- Phone Number: ________________________
Signature:
By signing below, I affirm that I am of legal age and that I understand the contents of this Living Will. I am executing this document voluntarily and without coercion.
Signature: ___________________________
Date: ________________________________
Witnesses:
This Living Will must be signed in the presence of two witnesses, neither of whom is my health care representative or related to me by blood, marriage, or adoption.
- Witness 1: __________________________
- Witness 2: __________________________