Louisiana Living Will
This Louisiana Living Will is made in accordance with the Louisiana Declaration Concerning Life-Sustaining Procedures Act. It is designed to express the wishes of the individual, referred to as the declarant, regarding medical treatment in circumstances where they are no longer able to communicate their decisions due to incapacity.
Please fill out the following information accurately to ensure your wishes are understood and respected.
Personal Information
- Full Name: ___________________________________________________
- Date of Birth: _______________________________________________
- Social Security Number: ______________________________________
- Address: _____________________________________________________
- City: ______________________ State: LA Zip: __________________
Declaration
I, ___________________________ (insert your full name), being of sound mind, willfully and voluntarily declare my desire that my dying shall not be artificially prolonged under the circumstances set forth below, and I hereby declare:
- If at any time I am incapacitated and (a) have a terminal and irreversible condition that will result in my death within a relatively short time, or (b) I am unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (c) I suffer from a condition that is not terminal but which is irreversible and which will result in my death without the use of life-sustaining procedures,
- I direct that such procedures be withheld or withdrawn when they serve only to prolong the process of dying, and that I be permitted to die naturally with only the provision of appropriate nutrition and hydration, pain relief, and comfort care.
This declaration only applies if I am unable to communicate my intentions and if my condition is as described above.
Additional Instructions (Optional)
You may provide additional instructions such as preferences regarding pain relief, hospice care, etc.
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Signature
This declaration is to be signed by the declarant in the presence of two witnesses who are not heirs or legatees of the declarant and who are not responsible for financing the declarant's medical care.
______________________________ ______________________________
Signature of Declarant Date
Witnesses:
- Witness 1 Name: _____________________________________________
- Witness 1 Signature: _________________________________________
- Witness 1 Address: ___________________________________________
- Witness 2 Name: _____________________________________________
- Witness 2 Signature: _________________________________________
- Witness 2 Address: ___________________________________________