Florida Living Will Declaration
This Living Will is made in accordance with the Florida Life-Prolonging Procedure Act of the Florida Statutes. This document outlines the desires and instructions of the undersigned regarding life-prolonging treatments and procedures in the event the individual becomes unable to communicate these wishes directly.
Personal Information
Full Name: ___________________________
Birth Date: ___________________________
Address: ___________________________
__________________________________________
City, State, Zip: ___________________________
Phone Number: ___________________________
Declaration
I, ___________________________ [Full Name], being of sound mind, willfully and voluntarily declare that my desires regarding medical treatment are as follows, should I become incapacitated and unable to personally communicate my medical treatment preferences:
Life-Prolonging Procedures
In the event I have a terminal condition, end-stage condition, or am in a persistent vegetative state, and my attending physician has determined that there is no reasonable medical probability of my recovery:
- I direct that life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying.
- I direct that I be given any medical treatment or procedure necessary to provide comfort care or alleviate pain, excluding life-prolonging procedures.
Artificially Provided Sustenance and Hydration
I further direct that, under the conditions described above:
- _________________________________ (initial) Artificial nutrition and hydration be withheld or withdrawn, except to the extent necessary to provide comfort care.
- _________________________________ (initial) Artificial nutrition and hydration be administered to the extent necessary to alleviate pain or provide comfort care.
Designation of Health Care Surrogate
I designate the following individual as my Health Care Surrogate to make medical decisions for me, including decisions about life-prolonging procedures, in the event I am unable to make my wishes known:
Name: ___________________________
Relationship: ___________________________
Phone Number: ___________________________
Alternate Surrogate (optional):
Name: ___________________________
Relationship: ___________________________
Phone Number: ___________________________
Signature
This living will is signed voluntarily as my free act and deed.
Date: ___________________________
Signature: ___________________________
Witness #1: ___________________________
Relationship to Declarant: ___________________________
Signature: ___________________________
Date: ___________________________
Witness #2: ___________________________
Relationship to Declarant: ___________________________
Signature: ___________________________
Date: ___________________________