Indiana Living Will Template
This document serves as a Living Will, established in accordance with the Indiana Living Will Declaration Act, allowing individuals to outline their preferences for medical treatment in the event they are no longer able to communicate their wishes.
Personal Information:
- Full Name: ___________________________
- Date of Birth: ________________________
- Address: ______________________________
- City: _________________________________
- State: Indiana
- Zip Code: _____________________________
Declaration:
I, _______________ (the "Declarant"), being of sound mind and not under the influence of any medication, drugs, or alcohol that might impair judgment or decision-making, hereby declare my wishes regarding the acceptance, continuation, discontinuation, or refusal of medical treatment, including artificially provided nutrition and hydration.
Directions Concerning Life-Prolonging Procedures:
In the event that I suffer a terminal illness or condition, where the use of life-prolonging measures would serve only to artificially prolong the process of dying, I direct the following:
- I wish to receive / not receive (circle one) life-prolonging medical procedures that artificially prolong the process of dying.
- I wish to receive / not receive (circle one) artificially provided nutrition and hydration, if my attending physician believes I will not recover from a vegetative state.
Health Care Representative:
I designate the following individual as my Health Care Representative to make medical treatment decisions on my behalf if I am unable to make or communicate such decisions:
- Name: _______________________________
- Relationship: ________________________
- Primary Phone: ______________________
- Alternate Phone: _____________________
Alternate Health Care Representative:
If my primary Health Care Representative is unavailable, unwilling, or unable to act on my behalf, I designate the following individual as my alternate Health Care Representative:
- Name: _______________________________
- Relationship: ________________________
- Primary Phone: ______________________
- Alternate Phone: _____________________
Signatures:
This Living Will is effective upon my signature and remains in effect unless I revoke it.
Declarant's Signature: ________________________
Date: ______________________________________
Witness Declaration:
I, _____________ (witness name), declare that the Declarant signed or acknowledged this Living Will in my presence, and that the Declarant appears to be of sound mind and not under duress, fraud, or undue influence.
Witness 1 Signature: _____________________
Date: __________________________________
Witness 2 Signature: _____________________
Date: __________________________________
State of Indiana}
This Living Will has been established in accordance with the laws of the State of Indiana and is intended to be valid in any jurisdiction, to the extent allowed by law.