Pennsylvania Living Will Template
This Living Will is created in accordance with the laws of the Commonwealth of Pennsylvania. It reflects my wishes regarding medical treatment in the event that I become unable to communicate my preferences.
Instructions for Use:
This document is meant to convey your wishes about medical treatment. Fill in the blanks with your personal information and preferences. Keep a copy for yourself and share copies with your healthcare proxies and family members.
Personal Information:
- Full Name: __________________________
- Date of Birth: ______________________
- Address: ___________________________
- City, State, ZIP: ____________________
- Phone Number: ______________________
Declaration:
If I am diagnosed with a terminal illness or a condition that results in my inability to make medical decisions, I direct my healthcare providers to provide or withhold the following treatments:
- Life-Sustaining Treatment: I do/do not wish to receive life-sustaining treatments (such as mechanical ventilation, resuscitation, or feeding tubes). (Please circle one)
- Pain Management: I want pain management provided even if it may hasten my death.
- Other Instructions: _______________________________________
Healthcare Proxy:
I appoint the following individual as my healthcare proxy to make decisions on my behalf when I am unable to do so:
- Name: ___________________________
- Relationship: _____________________
- Phone Number: ____________________
Signature:
I understand this document and affirm that it reflects my wishes. I sign this Living Will on this date:
Date: _________________________
Signature: ______________________
Witnesses:
This document must be witnessed by two individuals who do not stand to gain from my decisions:
- Witness 1 Name: __________________________
- Witness 1 Signature: ______________________
- Date: _________________________
- Witness 2 Name: __________________________
- Witness 2 Signature: ______________________
- Date: _________________________
This Living Will is duly executed according to the laws of the Commonwealth of Pennsylvania.