Kansas Living Will Template
This Living Will is created in accordance with the Kansas Living Will Act, K.S.A. 65-28,101 et seq. This document outlines your wishes regarding medical treatment in the event you become unable to communicate your preferences.
Personal Information:
- Name: ___________________________
- Date of Birth: _____________________
- Address: __________________________
- City, State, Zip Code: ____________
- Phone Number: ____________________
Declaration:
I, the undersigned, declare that if I become terminally ill or permanently unconscious, I do not wish to receive the following treatments:
- Cardiopulmonary resuscitation (CPR)
- Mechanical ventilation
- Artificial nutrition and hydration
- Other: _____________________________
In the event that I am unable to make decisions regarding my medical care, I designate the following person as my healthcare proxy:
Healthcare Proxy Information:
- Name: ___________________________
- Relationship: ______________________
- Address: __________________________
- City, State, Zip Code: ____________
- Phone Number: ____________________
Signature:
By signing below, I confirm that I understand the contents of this Living Will and that I am of sound mind. This document reflects my wishes regarding medical treatment.
Signature: ___________________________
Date: ________________________________
Witnesses:
Two witnesses must sign this document. They cannot be your healthcare proxy or related to you by blood, marriage, or adoption.
- Witness 1 Name: ____________________
- Witness 1 Signature: _______________
- Witness 1 Date: ____________________
- Witness 2 Name: ____________________
- Witness 2 Signature: _______________
- Witness 2 Date: ____________________