Pennsylvania Living Will Template
This Living Will is made in accordance with the Pennsylvania Consolidated Statutes, Title 20, Chapter 54. It expresses 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: ____________________________
Designation of Health Care Agent:
I hereby designate the following individual as my Health Care Agent to make medical decisions on my behalf if I am unable to do so:
- Name of Agent: ______________________
- Relationship to Me: __________________
- Address: _____________________________
- Phone Number: ______________________
Living Will Declaration:
If at any time I am diagnosed with a terminal condition or a condition that leaves me in a persistent state of unconsciousness, I direct that:
- Life-sustaining treatment be withheld or withdrawn.
- I should be kept comfortable and free from pain.
- My wishes regarding organ donation should be honored (if applicable).
Signature:
I understand that this document will only be effective when I am unable to make my own medical decisions. I have signed this Living Will on the date below.
Signature: ___________________________
Date: ________________________________
Witnesses:
This Living Will must be witnessed by two individuals who are not related to me and who do not stand to gain from my death. The witnesses must sign below:
- Witness 1: __________________________
- Witness 2: __________________________
By signing this document, I affirm that I am of sound mind and that I understand the contents of this Living Will.