Living Will

(Andre & Blaustein, LLP Format)

Living Will made this _____ day of  _______________, 2006. 

I, ___________________________ [PRINCIPAL], being of sound mind, willfully and voluntarily make known my desire that my life shall not be prolonged under the circumstances set forth below and do declare:

1.         If at any time I should (check each option desired):

(___)    have a terminal condition,

(___)    become in a coma with no reasonable expectation of regaining consciousness, or

(___)    become in a persistent vegetative state with no reasonable expectation of regaining significant cognitive function;

as defined in and established in accordance with the procedures set forth in paragraphs (2), (9), and (13) of Code Section 31-32-2 of the Official Code of Georgia Annotated, I direct that:

(A)       the application of life-sustaining procedures to my body be withheld or withdrawn and that I be permitted to die; and

(B)       (check only one of the following options): 

(___)  I want nourishment and hydration to be withheld or withdrawn. 

(___)  I want nourishment, but not hydration, to be withheld or withdrawn. 

(___)  I want nourishment withheld or withdrawn.  I authorize the withholding or withdrawal of hydration; provided, however, I do not authorize the withholding or withdrawal of hydration if hydration is required for my comfort and/or to alleviate pain. 

(___)  I do not want nourishment and hydration withheld or withdrawn. 

2.         In the absence of my ability to give directions regarding the use of such life‑sustaining procedures, it is my intention that this Living Will shall be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment and I accept the consequences from such refusal;

3.         I understand that I may revoke this Living Will at any time;

4.         I understand the full import of this Living Will, and I am at least 18 years of age and am emotionally and mentally competent to make this Living Will; and

5.         If I am a female and I have been diagnosed as pregnant, this living will shall have no force and effect unless the fetus is not viable and I indicate by initialing after this sentence that I want this living will to be carried out. 

Initialed:_________

                                                                                    Signed:__________________________________

                                                                                                [PRINCIPAL]

_______________________ (City), _______________________ (County), Georgia

I hereby witness this Living Will and attest that:

(1)     The declarant, __________________________ [PRINCIPAL], is personally known to me, and I believe the declarant to be at least 18 years of age and of sound mind;

(2)     I am at least 18 years of age;

(3)     To the best of my knowledge, at the time of the execution of the Living Will, I:

(A)       Am not related to the declarant by blood or marriage;

(B)       Would not be entitled to any portion of the declarant's estate by any will or by operation of law under the rules of descent and distribution of this state;

(C)       Am not the attending physician of declarant or an employee of the attending physician or an employee of the hospital or skilled nursing facility in which declarant is a patient;

(D)       Am not directly financially responsible for the declarant's medical care; and

(E)       Have no present claim against any portion of the estate of the declarant;

(4)      Declarant has signed this document in my presence as above instructed, on the date above first shown.

Witnesses:                                                              Addresses:

__________________________________                _________________________________

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