Indiana Living Will Template
This Living Will is created in accordance with Indiana state laws regarding advance directives. It allows you to express your wishes regarding medical treatment in the event that you are unable to communicate those wishes yourself.
Personal Information
- Name: ______________________________
- Date of Birth: ______________________
- Address: ____________________________
- City: _______________________________
- State: Indiana
- Zip Code: __________________________
Declaration
I, the undersigned, being of sound mind, voluntarily make this declaration to provide guidance for my medical treatment in the event that I become unable to communicate my wishes. I understand that this document will be effective only when I am unable to make my own healthcare decisions.
Healthcare Preferences
If I am diagnosed with a terminal illness or a condition that will lead to my death, I wish to make the following choices regarding my medical treatment:
- I do not wish to receive life-sustaining treatment if it only prolongs the dying process.
- I wish to receive comfort care, including pain relief, even if it may hasten my death.
- I wish to have my wishes respected regarding the use of artificial nutrition and hydration.
Designation of Healthcare Representative
If I am unable to make my own healthcare decisions, I appoint the following individual as my healthcare representative:
- Name: ______________________________
- Relationship: ______________________
- Phone Number: _____________________
Signatures
This Living Will must be signed in the presence of two witnesses or a notary public. By signing below, I confirm that I understand the contents of this document and that it reflects my wishes.
Signature: ____________________________ Date: _____________
Witness 1 Signature: __________________ Date: _____________
Witness 2 Signature: __________________ Date: _____________
Notary Acknowledgment (if applicable)
State of Indiana
County of _____________________________
Subscribed and sworn to before me on this ____ day of ____________, 20__.
Notary Public: ________________________
My Commission Expires: _______________