West Virginia Living Will Form

STATEOFWESTVIRGINIA

LIVINGWILL

TheKindofMedicalTreatmentIWantandDon’tWant

IfIHaveaTerminalConditionorAmInaPersistentVegetativeState

Livingwillmadethis dayof (month,year).

I,,beingofsoundmind,willfullyandvoluntarilydeclare

thatIwantmywishestoberespectedifIamverysickandnotabletocommunicatemywishesformyself. Intheabsenceofmyabilitytogivedirectionsregardingtheuseoflife-prolongingmedicalintervention,itismydesirethatmydyingshallnotbeprolongedunderthefollowingcircumstances:

IfIamverysickandnotabletocommunicatemywishesformyselfandIamcertifiedbyonephysicianwhohaspersonallyexaminedme,tohaveaterminalconditionortobeinapersistentvegetativestate(Iamunconsciousandamneitherawareofmyenvironmentnorabletointeractwithothers,)Idirectthatlife-prolongingmedicalinterventionthatwouldservesolelytoprolongthedyingprocessormaintainmeinapersistentvegetativestatebewithheldorwithdrawn. Iwanttobeallowedtodienaturallyandonlybegivenmedicationsorothermedicalproceduresnecessarytokeepmecomfortable. Iwanttoreceiveasmuchmedicationasisnecessarytoalleviatemypain.

IgivethefollowingSPECIALDIRECTIVESORLIMITATIONS:(Commentsabouttubefeedings,breathingmachines,cardiopulmonaryresuscitation,dialysis,andmentalhealthtreatmentmaybeplacedhere.MyfailuretoprovidespecialdirectivesorlimitationsdoesnotmeanthatIwantorrefusecertaintreatments.)

Itismyintentionthatthislivingwillbehonoredasthefinalexpressionofmylegalrighttorefusemedicalorsurgicaltreatmentandaccepttheconsequencesresultingfromsuchrefusal.

Iunderstandthefullimportofthislivingwill.

Signed

Address

Ididnotsigntheprincipal’ssignatureabovefororatthedirectionoftheprincipal. Iamatleasteighteenyearsofageandamnotrelatedtotheprincipalbybloodormarriage,entitledtoanyportionoftheestateoftheprincipaltothebestofmyknowledgeunderanywillofprincipalorcodicilthereto,ordirectlyfinanciallyresponsibleforprincipal’smedicalcare. Iamnottheprincipal’sattendingphysicianortheprincipal’s medical power of attorney representative or successor medical power of attorneyrepresentativeunderamedicalpowerofattorney.

Witness DATE Witness DATE

STATEOF

COUNTYOF

I, ,aNotaryPublicofsaidCounty,docertifythat

,asprincipal,and ,and ,aswitnesses,whosenamesaresignedtothewritingabovebearingdateonthe dayof ,20 ,havethisdayacknowledgedthesamebeforeme.

Givenundermyhandthis dayof ,20 .

Mycommissionexpires:

SignatureofNotaryPublic