North Carolina Living Will
This Living Will is made in accordance with the laws of the State of North Carolina. It expresses my wishes regarding medical treatment in the event that I become unable to communicate my decisions.
Personal Information
- Full Name: _______________________________
- Date of Birth: __________________________
- Address: ________________________________
- City, State, Zip: _______________________
- Phone Number: __________________________
Declaration
I, the undersigned, declare that if I am diagnosed with a terminal condition or if I am in a persistent vegetative state, I do not wish to have my life prolonged by medical treatment. I wish to receive only comfort care and pain relief.
Specific Instructions
In addition to the general declaration above, I provide the following specific instructions:
- 1. If I am unable to communicate, I do not want any life-sustaining treatment.
- 2. I wish to be kept comfortable and pain-free.
- 3. I do not wish to receive artificial nutrition or hydration if I am in a terminal condition.
Designation of Health Care Agent
If I am unable to make my own health care decisions, I appoint the following person as my health care agent:
- Name of Health Care Agent: __________________________
- Address: __________________________________________
- Phone Number: ____________________________________
Signatures
This Living Will must be signed and dated by me in the presence of two witnesses or a notary public.
Signature: ___________________________
Date: _______________________________
Witnesses:
- _____________________________ (Signature) - __________________________ (Date)
- _____________________________ (Signature) - __________________________ (Date)
This document is intended to provide guidance to my family and healthcare providers regarding my wishes. It is important that it be honored as per North Carolina law.