Official Virginia Living Will Document

Virginia Living Will

This Virginia Living Will is created in accordance with the Virginia Health Care Decisions Act. It allows you, the undersigned, to guide your healthcare providers and loved ones regarding your preferences for medical treatment if you become unable to communicate your wishes directly.

Part 1: Information of the Principal

Full Name: ___________________________

Date of Birth: ________________________

Address: ______________________________

City: ______________________ State: VA Zip Code: ___________

Phone Number: _________________________

Part 2: Treatment Preferences

Here, you may state your decisions regarding the refusal of life-sustaining treatment, artificially provided food, and hydration if you are in a terminal condition from which recovery is medically unexpected or in a persistent vegetative state.

• I wish to receive all available medical treatments, including those intended to extend my life, except as I specifically indicate below:
• ____ I do not want mechanical ventilation if I am incapable of breathing on my own.
• ____ I do not want cardiopulmonary resuscitation (CPR) if my heart stops beating.
• ____ I do not want artificial nutrition and hydration if I am unable to eat or drink by mouth.

Part 3: Additional Instructions

You may provide any specific wishes or instructions regarding your healthcare that you wish your healthcare providers and loved ones to follow, that have not been covered in the sections above.

Additional Instructions: ___________________________________________________________

____________________________________________________________________________________

Part 4: Designation of Health Care Agent

If you would like to designate a health care agent to make medical decisions on your behalf in the event you can no longer express your preferences, provide their information below:

Agent's Full Name: _______________________________

Relationship to You: _____________________________

Agent's Address: __________________________________

City: ________________ State: __ VA __ Zip Code: ________

Agent's Phone Number: ____________________________

Alternate Agent's Full Name: _______________________

Relationship to You: _______________________________

Alternate Agent's Address: ___________________________

City: ________________ State: __ VA __ Zip Code: ________

Alternate Agent's Phone Number: ______________________

Part 5: Signatures

This document must be signed in the presence of two witnesses, who must also sign. Witnesses cannot be anyone who is related to you, entitled to any part of your estate, the designated health care agent, or directly involved in your health care.

Principal's Signature: ______________________ Date: ____________

Witness 1 Signature: ______________________ Date: ____________

Witness 2 Signature: ______________________ Date: ____________

Having this Living Will does not prevent you from communicating your wishes about your health care directly at any time. This document can be revoked by you at any point by destroying the document or creating a new one that expresses your current health care preferences.