North Carolina Living Will
This Living Will is created in accordance with North Carolina General Statutes, Chapter 90, Article 3. A Living Will allows individuals to express their wishes regarding medical treatment in the event that they become unable to communicate those wishes during a medical crisis.
Personal Information:
- Full Name: ________________
- Date of Birth: ________________
- Address: ________________
- City: ________________
- State: North Carolina
- Zip Code: ________________
Declaration:
I, ________________ (name), being of sound mind, make this statement as a directive to be followed if I become unable to participate in decisions regarding my medical treatment.
In the event that I have a terminal condition, or I am in a persistent vegetative state, I wish to have the following treatment decisions honored:
- To administer comfort care and pain relief to the extent needed.
- To withhold or withdraw life-prolonging measures, including but not limited to:
- Mechanical ventilation
- Cardiopulmonary resuscitation (CPR)
- Dialysis
- Tube feeding
Appointment of Health Care Agent:
If applicable, I appoint the following individual as my health care agent to make medical decisions on my behalf:
- Name of Agent: ________________
- Phone Number: ________________
- Address: ________________
- Relationship to Me: ________________
Signatures:
This Living Will must be signed in the presence of two qualified witnesses, who are not related to me and who will not inherit from me:
Signed this ___ day of ____________, 20__.
Signature: ________________________
Witness 1:
- Name: ________________________
- Signature: ________________________
- Date: ________________
Witness 2:
- Name: ________________________
- Signature: ________________________
- Date: ________________