Pennsylvania Living Will Template
This Living Will is created in accordance with Pennsylvania law and outlines your wishes regarding medical treatment in case you are unable to communicate them yourself. Please complete the blanks with your information.
Patient Information:
Full Name: ______________________________
Date of Birth: ______________________________
Address: ______________________________
City, State, Zip: ______________________________
Declaration:
I, the undersigned, being of sound mind, wish to express my preferences regarding medical treatment in the event that I become unable to communicate my wishes due to a terminal illness or a persistent vegetative state. I hereby declare the following:
- In the event of a terminal illness or condition, I do not wish to receive treatment that merely prolongs the dying process.
- If I am in a persistent vegetative state, I prefer to be allowed to die naturally without artificial feeding or hydration.
- Should I experience severe pain that cannot be alleviated, I choose to receive palliative care even if it may hasten my death.
Healthcare Proxy:
I appoint the following individual as my healthcare agent to make medical decisions on my behalf if I am unable to do so:
Full Name of Healthcare Proxy: ______________________________
Address: ______________________________
City, State, Zip: ______________________________
Phone Number: ______________________________
Signatures:
I understand that this Living Will reflects my wishes and is to be followed by my healthcare providers.
Signed: ______________________________
Date: ______________________________
This document should be witnessed by two individuals who are not designated as the healthcare proxy and do not stand to benefit from my estate:
- Witness 1 Signature: ______________________________
- Witness 1 Name: ______________________________
- Witness 1 Address: ______________________________
- Witness 2 Signature: ______________________________
- Witness 2 Name: ______________________________
- Witness 2 Address: ______________________________
Note: It is recommended to keep a copy of this Living Will in an easily accessible location and share it with family members and your healthcare proxy.