Kansas Living Will
This Living Will is created in accordance with the Kansas Living Will Act (K.S.A. 65-28,101 et seq.). It outlines my wishes regarding medical treatment in the event that I become unable to communicate my preferences.
Personal Information:
- Name: ______________________________
- Date of Birth: ______________________
- Address: ____________________________
- City: _______________________________
- State: ______________________________
- Zip Code: __________________________
- Phone Number: ______________________
Declaration:
I, the undersigned, declare that if I become unable to make my own healthcare decisions, I wish to have the following instructions followed regarding my medical treatment:
- If I have a terminal condition, I do not want life-sustaining treatment that only prolongs the dying process.
- If I am in a persistent vegetative state, I do not wish to receive life-sustaining treatment.
- If I have an irreversible condition that causes me to be unable to make decisions, I wish to receive comfort care only.
Additional Instructions:
___________________________________________________________________________
___________________________________________________________________________
Signature:
I understand the contents of this Living Will and sign it voluntarily.
Signature: _____________________________
Date: _________________________________
Witnesses:
This Living Will must be witnessed by two individuals who are not related to me or entitled to any portion of my estate.
- Witness 1: ___________________________
- Witness 2: ___________________________
By signing this document, I confirm that I am of sound mind and that this Living Will reflects my wishes regarding medical treatment.