Pennsylvania Living Will Template
This Living Will is made in accordance with the laws of the Commonwealth of Pennsylvania. It expresses your wishes regarding medical treatment in the event that you become unable to communicate your decisions.
Instructions: Fill in the blanks with your personal information and preferences.
Personal Information:
- Name: ______________________________________
- Date of Birth: ______________________________
- Address: ____________________________________
- City, State, Zip Code: ______________________
Living Will Declaration:
I, the undersigned, being of sound mind, make this declaration to express my wishes regarding medical treatment in the event that I am unable to communicate my preferences due to a medical condition.
If I am diagnosed with a terminal illness or a condition that will result in my death within a short time, I wish to make the following choices regarding my medical care:
- I do not want life-sustaining treatment if it only prolongs the dying process.
- I want to receive pain relief and comfort care, even if it may hasten my death.
- If I am in a persistent vegetative state or have a terminal condition, I wish to forego artificial nutrition and hydration.
Additional Wishes:
Please specify any additional wishes regarding your medical treatment:
______________________________________________________
______________________________________________________
Signature:
I hereby declare that I am of legal age and that I understand the contents of this Living Will.
Signature: ______________________________________
Date: __________________________________________
Witnesses:
This Living Will must be signed in the presence of two witnesses who are not related to you or entitled to any part of your estate.
- Witness 1 Name: ______________________________
- Witness 1 Signature: __________________________
- Date: ______________________________________
- Witness 2 Name: ______________________________
- Witness 2 Signature: __________________________
- Date: ______________________________________
It is recommended that you keep a copy of this Living Will in a safe place and provide copies to your healthcare provider and family members.