Nebraska Living Will Template
This Living Will is created in accordance with the Nebraska Revised Statutes, Section 20-405. This document outlines your wishes regarding medical treatment in the event that you become unable to communicate your decisions.
Instructions: Fill in the blanks with your personal information and preferences.
Patient Information:
- Name: _______________________________
- Date of Birth: ______________________
- Address: ____________________________
- City: _______________________________
- State: ______________________________
- Zip Code: __________________________
Declaration:
I, the undersigned, being of sound mind, do hereby declare that if I am diagnosed with a terminal condition or if I am in a state of irreversible coma, I do not wish for my life to be prolonged by medical treatment. I wish to receive only comfort care. My specific wishes are as follows:
- In the event of a terminal condition, I do not want:
- Cardiopulmonary resuscitation (CPR)
- Mechanical ventilation
- Dialysis
- Tube feeding
- If I am in a persistent vegetative state, I wish for:
- Comfort measures only
- No extraordinary means to prolong life
Signature:
By signing below, I affirm that I am of legal age and that I understand the contents of this Living Will.
Signature: _____________________________
Date: _________________________________
Witnesses:
This document must be signed in the presence of two witnesses who are not related to the patient or entitled to any part of the patient’s estate.
- Witness 1 Name: ______________________
- Witness 1 Signature: __________________
- Date: ________________________________
- Witness 2 Name: ______________________
- Witness 2 Signature: __________________
- Date: ________________________________
This Living Will is valid in the state of Nebraska and reflects my wishes regarding medical treatment.