Kentucky Living Will Template
This Living Will is created in accordance with the laws of the Commonwealth of Kentucky. It expresses your wishes regarding medical treatment in the event that you become unable to communicate your decisions.
Personal Information
- Name: ___________________________
- Date of Birth: ___________________________
- Address: ___________________________
- City, State, Zip Code: ___________________________
Declaration
I, the undersigned, being of sound mind, voluntarily make this declaration to provide guidance regarding my medical treatment in the event that I am unable to communicate my wishes.
Healthcare Decisions
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- Life-sustaining treatment be withheld or withdrawn.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, with dignity.
Specific Instructions
In addition to the above, I wish to express my preferences regarding the following:
- Do Not Resuscitate (DNR) Order: ___________ (Yes/No)
- Artificial Nutrition and Hydration: ___________ (Yes/No)
- Pain Management: ___________ (Specify preferences)
Designation of Healthcare Surrogate
If I am unable to make my own healthcare decisions, I appoint the following individual as my healthcare surrogate:
- Name: ___________________________
- Relationship: ___________________________
- Phone Number: ___________________________
Signatures
This Living Will must be signed and dated in the presence of two witnesses or a notary public.
Signature: ___________________________
Date: ___________________________
Witnesses
Witness 1:
- Name: ___________________________
- Signature: ___________________________
- Date: ___________________________
Witness 2:
- Name: ___________________________
- Signature: ___________________________
- Date: ___________________________
This Living Will is intended to provide clear instructions for my healthcare providers and loved ones regarding my wishes for medical treatment.