Printable  Living Will Template for Pennsylvania Customize Document Here

Printable Living Will Template for Pennsylvania

A Pennsylvania Living Will form is a legal document that allows individuals to express their wishes regarding medical treatment in the event they become unable to communicate those wishes themselves. This important form ensures that your preferences for end-of-life care are respected and followed. By completing a Living Will, you can provide clarity and peace of mind for both yourself and your loved ones during difficult times.

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Outline

In Pennsylvania, the Living Will form serves as a crucial document that allows individuals to express their wishes regarding medical treatment in the event they become unable to communicate their preferences due to a serious illness or injury. This form empowers individuals to make decisions about life-sustaining measures, such as resuscitation and artificial nutrition, ensuring that their values and desires are respected even when they cannot voice them. By clearly outlining one's preferences, the Living Will helps to alleviate the emotional burden on family members and healthcare providers during difficult times. It is important to understand the specific requirements for completing and witnessing the form, as well as the implications of the choices made within it. This document not only provides clarity but also fosters open conversations about end-of-life care, allowing individuals to take control of their healthcare decisions in a thoughtful and compassionate manner.

Preview - Pennsylvania Living Will Form

Pennsylvania Living Will Template

This Pennsylvania Living Will Template is designed to help residents of Pennsylvania create a document that clearly states their wishes regarding medical treatment in the event they become unable to communicate due to illness or incapacity. This template is guided by the Pennsylvania Advance Health Care Directive Act.

Personal Information

Full Name: ________________

Date of Birth: ________________

Address: ___________________________________________

City: ________________ State: Pennsylvania Zip Code: ___________

Living Will Declarations

I, _________________________, being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below. I hereby direct that, in accordance with the Pennsylvania Advance Health Care Directive Act, the following preferences about my health care treatment be followed.

Treatment Preferences

Please indicate your treatment preferences in the scenarios described.

  1. In the event of terminal condition:
  2. ____ Do not prolong my life through the following means (please specify): ________________

    ____ I wish to receive all available treatments to prolong life.

  3. In the event of permanent unconsciousness:
  4. ____ Do not prolong my life through the following means (please specify): ________________

    ____ I wish to receive all available treatments to prolong life.

  5. In the event of end-stage medical condition:
  6. ____ Do not prolong my life through the following means (please specify): ________________

    ____ I wish to receive all available treatments to prolong life.

Power of Attorney for Health Care

I designate the following individual as my attorney-in-fact (health care agent) to make any and all health care decisions for me, in accordance with the Pennsylvania Advance Health Care Directive Act, in the event that I become unable to communicate those decisions myself.

Name of Attorney-in-fact: ______________________________

Relationship: _____________________________________

Phone Number: _____________________________________

Alternate Attorney-in-fact: __________________________

Relationship: _____________________________________

Phone Number: _____________________________________

Signature

This document is effective upon my signature. I understand that I may amend or revoke this document at any time. I am aware that this document will be available to my physician and medical personnel in accordance with Pennsylvania law.

Date: ________________

Signature: ______________________________

Print Name: ______________________________

Witness Declaration

I declare that the individual signing this document is personally known to me and appears to be of sound mind and acting willingly and free from duress. He or she has declared to me that this document reflects his or her wishes regarding medical treatment.

Witness 1 Signature: ______________________________

Print Name: ______________________________

Date: ________________

Witness 2 Signature: ______________________________

Print Name: ______________________________

Date: ________________

Document Data

Fact Name Details
Purpose A Pennsylvania Living Will outlines a person's wishes regarding medical treatment in case they become unable to communicate those wishes themselves.
Governing Law The Pennsylvania Living Will is governed by the Pennsylvania Consolidated Statutes, Title 20, Chapter 54.
Eligibility Any adult who is at least 18 years old and of sound mind can create a Living Will in Pennsylvania.
Signature Requirements The document must be signed by the person making the Living Will or by another person at their direction and in their presence.
Witnesses Two witnesses must sign the Living Will. They cannot be relatives, beneficiaries, or employees of a healthcare facility where the person is a patient.
Revocation A Living Will can be revoked at any time by the person who created it, either verbally or in writing.
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