Living Will Declaration
DECLARATION — ILLINOIS LIVING WILL This declaration is made on the information supplied in the interview. I, the information supplied in the interview, being of sound mind, willfully and voluntarily make known my desire that my moment of death shall not be artificially postponed. If at any time I should have an incurable and irreversible injury, disease, or illness judged to be a terminal condition by my attending physician who has personally examined me and has determined that my death is imminent except for death delaying procedures, I direct that such procedures which would only prolong the dying process be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, sustenance, or the performance of any medical procedure deemed necessary by my attending physician to provide me with comfort care. In the absence of my ability to give directions regarding the use of such death delaying procedures, it is my intention that this declaration shall be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal. the information supplied in the interviewOther specific directions: the information supplied in the interview the information supplied in the interview Signed: City, County and State of Residence: the information supplied in the interview Witnesses The declarant is personally known to me and I believe the declarant to be of sound mind. I saw the declarant sign the declaration in my presence (or the declarant acknowledged in my presence that the declarant had signed the declaration) and I signed the declaration as a witness in the presence of the declarant. I did not sign the declarant's signature above for or at the direction of the declarant. At the date of this instrument, I am not entitled to any portion of the estate of the declarant according to the laws of intestate succession or, to the best of my knowledge and belief, under any will of the declarant or other instrument taking effect at the declarant's death, or directly financially responsible for the declarant's medical care. Witness 1: Witness 2: Pregnancy rule Under 755 ILCS 35/3(c), the declaration of a qualified patient diagnosed as pregnant by the attending physician has no force and effect as long as the attending physician believes the fetus could develop to live birth with continued death-delaying procedures. This is a statutory limitation, not a customer election. Nutrition and hydration Under 755 ILCS 35/2, nutrition and hydration shall not be withdrawn or withheld from a qualified patient if the withdrawal or withholding would result in death solely from dehydration or starvation rather than from the existing terminal condition. Existing health-care agent coordination This Living Will does not appoint an agent. Under 755 ILCS 35/3.5, the declaration is not operative while an available authorized health-care agent can make decisions concerning life-sustaining or death-delaying procedures. Separate Medical Order This Living Will is not an Illinois POLST. Current Illinois law does not require POLST or a similar form in order to put an operative Living Will declaration into effect.