Living Will Form
A Living Will or Power of Attorney in case of incapacity is a document used to express health care wishes in case a person becomes incompetent or unable to communicate their wishes. This living will form is not a document that sets out how a person’s assets should be distributed after death. 

Parties 
Grantor: the person whose health care wishes are being expressed in this document
Attorney: person chosen by the Grantor to act on his/her behalf if Grantor is incompetent and unable to do so
Alternate Attorney: person chosen by the Grantor to act on his/her behalf if Attorney is unable or unwilling to act as such

Information needed to complete this Living Will form
You will need to decide or collect the following information before completing this document:

  1. Name and address of Attorney
  2. Name and address of Alternate Attorney (if applicable)
  3. Determine if Grantor wishes to include the various wishes listed below

When to use this Living Will form
All adults benefit from having a Living Will in case of emergency.

Specification of this Living Will Form
Grantor has the choice of including the following options into this Living Will:

  1.  Refusal to be kept alive by artificial means: in case there is no reasonable expectation that Grantor will recover from a severe mental or physical incapacity, by selecting this option, the Grantor is expressing his/her wish to be kept alive through medication, therapeutic intervention or all other artificial means.
  2. Refusal of certain treatment: by selecting this option, the Grantor is expressing his/her desire to refuse mechanical respiration (such as ventilators), electrical or mechanical heart resuscitation (such as CPR or use of defibrillators) and nasogastric tube feeding. This option includes a wish that all pain medications be received even though it might accelerate the Grantor’s death. Grantor also has the option of adding other treatments which he/she wishes to refuse.
  3. Administration of property: by selecting this option, the Grantor gives the Attorney the authority to administer his/her property and to make any decisions that may be needed regarding such property.
  4. Other Instructions: this option allows the Grantor to include any other instructions which he/she may wish to give the Attorney.

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