This West Virginia Living Will is a legal document that outlines your wishes regarding medical treatment in the event you are unable to communicate those wishes yourself. It is created in accordance with the West Virginia Health Care Decisions Act.
Full Name: ___________________________________________
Date of Birth: ________________________________________
Address: _____________________________________________
Declaration
I, ________________________ [Your Name], residing at ________________________ [Your Address], being of sound mind, hereby make this Living Will to guide my healthcare providers and loved ones about my desires concerning medical treatments and life-sustaining measures.
Directions for Health Care
I understand that if I become unable to make my own health care decisions, this document will serve to direct those making decisions on my behalf. Accordingly, I direct that:
- Life-sustaining treatment should be withheld or withdrawn if I am in a persistent vegetative state or if my condition is terminal and treatment would only prolong the process of dying.
- Artificial nutrition and hydration are to be withheld or withdrawn if the situation in item 1 applies, unless I have indicated otherwise below.
- I desire that pain relief measures be provided at all times to ensure my comfort, even if it may hasten my death.
Additional Instructions (optional):
________________________________________________________________
________________________________________________________________
Designation of Health Care Surrogate
In the event I am unable to make my own health care decisions, I designate the following individual as my health care surrogate:
Name: _______________________________________________
Relation: ____________________________________________
Phone Number: _______________________________________
Alternate Surrogate (optional):
Name: _______________________________________________
Relation: ____________________________________________
Phone Number: _______________________________________
Organ Donation (optional)
I wish to donate only the following organs/tissues: _______________
OR
I wish to donate any needed organs/tissues.
Signature and Date
This Living Will is executed on this ____ day of __________, 20__.
Signature: ___________________________________________
Printed Name: ________________________________________
Witness Declaration
This Living Will was signed in my presence and, to the best of my knowledge, the signatory is of sound mind and not under any duress or undue influence.
Witness 1 Signature: __________________________________
Printed Name: ________________________________________
Date: _______________________________________________
Witness 2 Signature: __________________________________
Printed Name: ________________________________________
Date: _______________________________________________