Pennsylvania Living Will Template
This Living Will is made pursuant to Pennsylvania state law. It outlines your wishes regarding medical treatment in the event that you become unable to communicate those wishes yourself.
Please fill in the blanks with your personal information.
Individual Information:
- Name: ______________________________
- Date of Birth: ______________________
- Address: _____________________________
- City: ________________________________
- State: Pennsylvania
- Zip Code: ____________________________
Declaration:
I, [Your Full Name], hereby declare this Living Will to express my wishes regarding medical treatment if I am diagnosed with a terminal illness, become permanently unconscious, or am unable to communicate my preferences.
Specific Wishes:
- If I am in a terminal condition, I do not wish to receive life-sustaining treatment that would only prolong the dying process.
- If I am in a persistent vegetative state, I do not wish to receive life-sustaining treatment.
- If I am unable to make my own decisions, I want my healthcare provider to make decisions based on the values I have expressed to them.
If I am not able to communicate my wishes, I designate the following person to make healthcare decisions on my behalf:
- Name: ______________________________
- Relationship: _______________________
- Phone Number: ______________________
Signatures:
By signing below, I acknowledge that I understand the content of this Living Will and that these are my wishes.
Signature: ___________________________ Date: _______________
Witness Signature: ___________________ Date: _______________
Witness Signature: ___________________ Date: _______________