LWHCSD

Kentucky Living Will Directive and Health Care Surrogate Designation of

My wishes regarding life-prolonging treatment and artificially provided nutrition and hydration to be provided to me if I no longer have decisional capacity, have a terminal condition, or become permanently unconscious have been indicated by checking and initialing the appropriate lines below.

Health Care Surrogate Designation

I desire to name a health care surrogate

Living Will Directive

If I do not designate a health care surrogate, the following are my directions to the attending physcian. If I have designated a health care surrogate, my surrogate shall comply with my wishes as indicated below. By checking and initialing the lines below, I specifically:

 

Do you wish to authorize your surrogate to make life prolonging choices on your behalf?
Life Prolonging Treatment (select one)
Nourishment and/or Fluids (select one)
Shall my surrogate be authorized to act in my best interest?

Organ Donation Elections

 

Organ Donation Election
Organ Donation Specification Detail (select as you wish)

If you opted to provide a detailed organ donation, the list below contains the current set of possible donations.

  • Organs
    • Heart
    • Lungs
    • Liver
    • Pancreas
    • Kidneys
    • Small Bowel
  • Tissues
    • Skin – out most layer from lower trunk and abdomen
    • Bone
    • Heart valves
    • Leg veins
    • Pericardium
    • Vertibral bodies
  • Eyes
    • Corneas – out most layer
    • Sclera – shell
    • Entire eye

In the absence of my ability to give directions regarding the use of life-prolonging treatment and artificially provided nutrition and hydration, it is my intention that this directive shall be honored by my attending physician, my family, and any surrogate designated pursuant to this directive as the final expression of my legal right to refuse medical or surgical treatment and I accept the consequences of the refusal.

If I have been diagnosed as pregnant and that diagnosis is known to my attending physician, this directive shall have no force or effect during the course of my pregnancy.

I understand the full import of this directive and I am emotionally and mentally competent to make this directive.

Signed on this Day, Month, and Year.

NOTARY BLOCK

COMMONWEALTH OF KENTUCKY, 

 

County

Before me, the undersigned authority, came the grantor who is of sound mind and eighteen (18) years of age or older, and acknowledged that he/she voluntarily dated and signed this writing or directed it to be signed and dated as above.

Done this                   day of                    , 20

 

Signature of Notary Public

 

Date commission expires