Pennsylvania Living Will
This Living Will is created under the laws of the Commonwealth of Pennsylvania. It expresses my wishes regarding medical treatment in the event I become unable to communicate my wishes.
Principal Information:
- Full Name: ___________________________
- Date of Birth: ______________________
- Address: ___________________________
Instructions:
If at any time I am diagnosed with a terminal illness or am in a state of permanent incapacity, I hereby state my wishes regarding medical treatment:
- I do not wish to receive life-sustaining treatment if I am unable to communicate my wishes.
- I wish to receive palliative care to ensure comfort during my final days.
- If I am in a coma and my condition is deemed irreversible, I request that all life-support systems be withdrawn.
- I consent to the withholding or withdrawal of artificial nutrition and hydration.
Additional Wishes:
____________________________________________________________________
____________________________________________________________________
Signature: ___________________________
Date: _______________________________
Witness Information:
- Witness #1 Name: ___________________
- Witness #1 Signature: ______________
- Witness #2 Name: ___________________
- Witness #2 Signature: ______________