Virginia Living Will Template
This document serves as a Living Will, designed to be valid in the state of Virginia, in compliance with the Virginia Health Care Decisions Act. It is intended for the purpose of providing instructions regarding the use or non-use of life-prolonging procedures in the event that I, ____________ [full legal name], become incapable of making my own health care decisions.
Part 1: Declaration
I, ____________ [full legal name], residing at ____________ [address], being of sound mind, hereby make this declaration to guide my health care providers and loved ones regarding my wishes about medical treatment, should I become unable to communicate these wishes myself.
Part 2: Appointment of Health Care Agent
In the event that I am not able to make my own health care decisions, I hereby designate the following individual as my Health Care Agent:
- Name: ____________
- Relationship: ____________
- Address: ____________
- Phone Number: ____________
Part 3: Directions for Health Care
If at any time I should have a condition which is terminal, where the application of life-prolonging procedures would only serve to artificially delay the moment of my death, and where my attending physician and one other physician determine that my condition is irreversible and incurable, I direct the following:
- That no life-prolonging measures be taken; this includes mechanical ventilation, resuscitation, tube feeding, and other forms of artificial nutrition and hydration.
- To receive only treatment that eases pain and suffering and contributes to my comfort, even if such treatment hastens the moment of my death.
- That I be allowed to die naturally, with dignity, and in a place and manner of my choosing, to the extent possible and lawful.
Part 4: Organ and Tissue Donation
I express my wishes regarding organ and tissue donation as follows:
- I wish to donate only the following organs/tissues: ____________.
- I wish to donate any needed organs or tissues.
- I do not wish to donate any organs or tissues.
Part 5: Execution
This Living Will is executed this ____________ day of ____________ [month], ____________ [year], in the presence of the undersigned witnesses, affirming that I sign this document voluntarily, in good faith, and with a full understanding of its significance.
__________________________________
Signature of Declarant
We, the undersigned, declare that the declarant appears to be of sound mind and free from duress at the time of signing this document, and that we are not the appointed Health Care Agent, nor are we the declarant's attending physician, nor are we entitled to any portion of the declarant's estate upon their decease under a will currently existing or by operation of law.
Witness 1: ____________________________________
Address: ______________________________________
Witness 2: ____________________________________
Address: ______________________________________