Indiana Living Will Template
This Indiana Living Will document is prepared in accordance with the Indiana Living Will Declaration Act (IC 16-36-4). It serves as a legally binding document that communicates your healthcare preferences should you become unable to make those decisions yourself. Please provide the requested information and review your selections carefully.
Personal Information
Full Name: ___________________________________________________________
Date of Birth: _____________________
Address: ______________________________________________________________
City: _____________________________ State: INZip Code: _________
Phone Number: _______________________
Declaration
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. This declaration reflects my firm and settled commitment to decline life-sustaining treatment and artificial nutrition and hydration if I cannot make decisions for myself and am in a state as described below.
Directions for Health Care
1. Terminal Condition: If I am in a terminal condition where the application of life-sustaining treatment would only serve to artificially prolong my dying, I direct that such treatments be withheld or withdrawn. I wish to be allowed to die naturally with only the provision of appropriate comfort care and pain relief.
2. Permanent Unconsciousness: If I am in a permanent unconscious state, such as an irreversible coma or persistent vegetative state, and there is no reasonable expectation of recovery, I direct that all forms of life-sustaining treatment, including artificial nutrition and hydration, be withheld or withdrawn so that I may die naturally.
3. Additional Directions:_______________________________________________________________________
_________________________________________________________________________
Appointment of Health Care Representative
I hereby appoint the following individual as my Health Care Representative to make health care decisions for me if I am unable to make such decisions for myself.
Name of Health Care Representative: ________________________________________
Relationship to me: _________________________________________________________
Alternate Health Care Representative (if primary is unavailable): ________________________
Relationship to me: _________________________________________________________
Signatures
This Living Will is executed on the ______ day of ________________, 20____.
_____________________________________________
Signature of Declarant
I declare under penalty of perjury under the laws of Indiana that the person signing this document is personally known to me, that the declarant signed or acknowledged this Indiana Living Will in my presence, and appears to be of sound mind and under no duress, fraud, or undue influence.
Witness 1: ____________________________________________ Date: _______________
Witness 2: ____________________________________________ Date: _______________
Important Information: This document should be kept in a place where it is easily accessible. Provide a copy to your Health Care Representative, physician, and any other healthcare providers. A copy of this document is as legally valid as the original.
Note: This template is provided for general informational purposes only and may not meet all the legal requirements of your specific circumstance. It is recommended that you consult with a qualified attorney to ensure your rights and wishes are properly represented.