Kentucky Living Will Form

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Kentucky Living Will Form

Use this form to make a living will in Kentucky. Complete this form to make the future plans for your health care.

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LIVING WILL DIRECTIVE
My wishes regarding life-prolonging treatment and artificially provided nutrition and hydration to be provided to me if I no
longer have decisional capacity, have a terminal condition, or become permanently unconscious have been indicated by
checking and initialing the appropriate lines below. By checking and initialing the appropriate lines, I specifically:
…. Designate ……………………………………………………… as my health care surrogate(s) to make health care decisions for
me in accordance with this directive when I no longer have decisional capacity. If ………………………………………………………
refuses or is not able to act for me, I designate ……………………………………………………… as my health care surrogate(s).
Any prior designation is revoked.
If I do not designate a surrogate, the following are my directions to my attending physician. If I have designated a
surrogate, my surrogate shall comply with my wishes as indicated below:
…. Direct that treatment be withheld or withdrawn, and that I be permitted to die naturally with only the administration of
medication or the performance of any medical treatment deemed necessary to alleviate pain.
…. DO NOT authorize that life-prolonging treatment be withheld or withdrawn.
…. Authorize the withholding or withdrawal of artificially provided food, water, or other artificially provided nourishment or
fluids.
…. DO NOT authorize the withholding or withdrawal of artificially provided food, water, or other artificially provided
nourishment or fluids.
…. Authorize my surrogate, designated above, to withhold or withdraw artificially provided nourishment or fluids, or other
treatment if the surrogate determines that withholding or withdrawing is in my best interest; but I do not mandate that
withholding or withdrawing.
…. Authorize the giving of all or any part of my body upon death for any purpose specified in KRS 311.185.
…. DO NOT authorize the giving of all or any part of my body upon death.
In the absence of my ability to give directions regarding the use of life-prolonging treatment and artificially provided
nutrition and hydration, it is my intention that this directive shall be honored by my attending physician, my family, and any
surrogate designated pursuant to this directive as the final expression of my legal right to refuse medical or surgical
treatment and I accept the consequences of the refusal.
If I have been diagnosed as pregnant and that diagnosis is known to my attending physician, this directive shall have no
force or effect during the course of my pregnancy.
I understand the full import of this directive and I am emotionally and mentally competent to make this directive.
Signed this …. day of ………., 2005.
Grantor: ___________________________
Address: ___________________________In our joint presence, the grantor, who is of sound mind and eighteen (18) years of age, or older, voluntarily dated and
signed this writing or directed it to be dated and signed for the grantor.
Witness: ___________________________
Address: ___________________________
Witness: ___________________________
Address: ___________________________
Execution of this document restricts withholding and withdrawing of some medical procedures. Consult Kentucky Revised
Statutes or your attorney.
Page 2 of 2Form 2: Notary Public
Page 1 of 2
LIVING WILL DIRECTIVE
My wishes regarding life-prolonging treatment and artificially provided nutrition and hydration to be provided to me if I no
longer have decisional capacity, have a terminal condition, or become permanently unconscious have been indicated by
checking and initialing the appropriate lines below. By checking and initialing the appropriate lines, I specifically:
…. Designate ……………………………………………………… as my health care surrogate(s) to make health care decisions for
me in accordance with this directive when I no longer have decisional capacity. If ………………………………………………………
refuses or is not able to act for me, I designate ……………………………………………………… as my health care surrogate(s).
Any prior designation is revoked.
If I do not designate a surrogate, the following are my directions to my attending physician. If I have designated a
surrogate, my surrogate shall comply with my wishes as indicated below:
…. Direct that treatment be withheld or withdrawn, and that I be permitted to die naturally with only the administration of
medication or the performance of any medical treatment deemed necessary to alleviate pain.
…. DO NOT authorize that life-prolonging treatment be withheld or withdrawn.
…. Authorize the withholding or withdrawal of artificially provided food, water, or other artificially provided nourishment or
fluids.
…. DO NOT authorize the withholding or withdrawal of artificially provided food, water, or other artificially provided
nourishment or fluids.
…. Authorize my surrogate, designated above, to withhold or withdraw artificially provided nourishment or fluids, or other
treatment if the surrogate determines that withholding or withdrawing is in my best interest; but I do not mandate that
withholding or withdrawing.
…. Authorize the giving of all or any part of my body upon death for any purpose specified in KRS 311.185.
…. DO NOT authorize the giving of all or any part of my body upon death.
In the absence of my ability to give directions regarding the use of life-prolonging treatment and artificially provided
nutrition and hydration, it is my intention that this directive shall be honored by my attending physician, my family, and any
surrogate designated pursuant to this directive as the final expression of my legal right to refuse medical or surgical
treatment and I accept the consequences of the refusal.
If I have been diagnosed as pregnant and that diagnosis is known to my attending physician, this directive shall have no
force or effect during the course of my pregnancy.
I understand the full import of this directive and I am emotionally and mentally competent to make this directive.
Signed this …. day of ………., 2005.
Grantor: ___________________________
Address: ___________________________COMMONWEALTH OF KENTUCKY)
…………………………….. COUNTY)
Before me, the undersigned authority, came the grantor who is of sound mind and eighteen (18) years of age, or older,
and acknowledged that he voluntarily dated and signed this writing or directed it to be signed and dated as above.
Done this …. day of …….., 2005.
Notary Public: ___________________________
Date Commission Expires: ___________________________
Execution of this document restricts withholding and withdrawing of some medical procedures. Consult Kentucky Revised
Statutes or your attorney