California Living Will Template
This document serves as a Living Will, also known as an Advance Health Care Directive, in accordance with the California Probate Code Section 4700-4701. It is designed to express the desires of the individual concerning health care decisions when they are unable to communicate their wishes directly.
Part 1: Information of the Principal
Name of Principal: ________________________________________________________
Date of Birth: ___________________________________________________________
Address: __________________________________________________________________
Part 2: Health Care Directives
This section declares my wish concerning the provision, withholding, or withdrawal of treatment to keep me alive, as well as the provision of pain relief.
Initial the statement that applies:
- ____ I do not want my life to be prolonged if (i) I am in an irreversible comatose state with no reasonable chance of recovery or (ii) the burdens of treatment outweigh the expected benefits.
- ____ I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.
Part 3: Selection of Primary Physician
Name of Primary Physician: _________________________________________________
Physician's Phone Number: _________________________________________________
If the primary physician is unwilling or unable to act as such, I hereby designate the following physician as my alternate choice:
Name of Alternate Physician: ______________________________________________
Physician's Phone Number: _________________________________________________
Part 4: Special Instructions
In this section, you may describe any specific wishes or instructions for your health care. This may include your thoughts on artificial nutrition and hydration, and any treatments you do or do not desire:
Special Instructions: _____________________________________________________
__________________________________________________________________________
Part 5: Signature
I understand that I have the right to revoke this directive at any time. By signing below, I affirm that I am mentally competent to make this will and that I understand its contents.
Signature: _______________________________________ Date: _________________
Part 6: Witness Statement
My witnessing of the principal’s signature confirms that the principal seems to be of sound mind and not under duress, fraud, or undue influence. Furthermore, I am not the principal's health care provider, an employee of the health care provider, the operator of a community care facility, an employee of an operator of a community care facility, nor the principal's appointed health care agent.
Name of Witness: _________________________________________________________
Signature of Witness: _______________________________ Date: _______________
Notice: This document does not authorize a physician or any other health care provider to end life other than to permit the natural process of dying.