LWHCSD Kentucky Living Will Directive and Health Care Surrogate Designation of Full Legal Name (First Middle Last) * Date of Birth * 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 Box Checked Health Care Surrogate Health Care Surrogate Initial here to validate your choice(s) 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? * Yes No Life Prolonging Treatment (select one) Direct that treatment be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of an medical treatment deemed necessary to alleviate pain. DO NOT authorize that life-prolonging treatment be withheld or withdrawn. Initial to confirm your life prolonging treatment choice Nourishment and/or Fluids (select one) Authorize the withholding or withdrawl of artificially provided food, water, or other artificially provided nourishment or fluids. DO NOT authorize the withholding or withdrawl of artificially provided food, water, or other artificially provided nourishment or fluids. Initial to confirm your nourishment / fluids choice Shall my surrogate be authorized to act in my best interest? As designated on the previous page, to withhold or withdraw artificially provided nourishment or fluids, or other treatment if the surrogate determines that the withholding or withdrawing is in my best interest; but I do not mandate that withholding or withdrawing. DO NOT authorize my surrogate to withhold or withdraw artificially provided nourishment or fluids. Initial to confirm surrogate authorization Organ Donation Elections Organ Donation Election I do not wish to donate any organs I will donate any needed organs, tissues, and eyes/corneas I wish to specify among organs, tissues, eyes, and corneas (select specifically below) I wish to specify my donation in more detail (specify in detail below) Organ Donation Specification Detail (select as you wish) All needed organs All needed tissues Corneas Eyes Other Initial to confirm Organ Donation Specification choices 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 Only the specified organs/tissues as listed: Initial to confirm organ donation detailed choices 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. Day * Month * Year * Signature of Grantor * Address of Grantor * Signature of Witness * Address of Witness * Signature of Witness * Address of Witness * Submit 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 If you are human, leave this field blank.