Pennsylvania Living Will Template
This Living Will is prepared in accordance with Pennsylvania law regarding advance medical directives. It allows you to express your wishes regarding medical treatment in the event that you become unable to communicate them yourself.
Instructions: Fill out the blanks below with your personal information and details about your healthcare preferences.
Personal Information
- Full Name: ____________________________
- Address: ____________________________
- City, State, Zip: ____________________________
- Date of Birth: ____________________________
Healthcare Preferences
If I am diagnosed with a terminal illness, or if I am in a state of permanent unconsciousness, I do not wish for my life to be prolonged by:
- Artificial ventilation
- Cardiopulmonary resuscitation (CPR)
- Nutritional or hydration support
Designation of Healthcare Agent
I designate the following person as my healthcare agent to make medical decisions on my behalf if I am unable to do so:
- Name of Agent: ____________________________
- Address of Agent: ____________________________
- Phone Number of Agent: ____________________________
Signatures
This Living Will must be signed and dated in order to be valid.
Signature: ____________________________
Date: ____________________________
Witness 1: ____________________________
Date: ____________________________
Witness 2: ____________________________
Date: ____________________________
Note: Witnesses should not be family members or anyone named in this document. It is advisable to consult an attorney or healthcare professional for assistance.