Ohio Living Will
This document serves as a Living Will, designed in accordance with the Ohio Living Will Act (Ohio Revised Code Chapter 2133). It is a legal document that records an individual's healthcare preferences in the event they become unable to communicate these decisions due to incapacitation.
Part 1: Principal Information
Full Name: ___________________________________________________
Birth Date: ___________________________________________________
Address: ___________________________________________________
City: ___________________________ State: OH Zip Code: ___________________
Part 2: Health Care Directives
In the event that I am unable to make healthcare decisions for myself due to incapacitation, I hereby direct the following:
- Lifesaving Treatment: In situations where my life can only be sustained by life support and there is no reasonable expectation of recovery,
- ____ I wish to receive all life-sustaining treatments, including resuscitation.
- ____ I do not wish to receive the following treatments: ________________________________.
- Artificial Nutrition and Hydration: In the case that I cannot feed myself and require artificial means of nutrition and hydration,
- ____ I consent to the use of artificially provided food and water.
- ____ I do not consent to the use of artificial nutrition and hydration.
- End-of-Life Care: Should my condition be irreversible and incurable,
- ____ I wish to receive treatment to alleviate pain and suffering, even if it may not prolong life.
- ____ I refuse any treatments that serve only to prolong the dying process.
Part 3: Health Care Power of Attorney
I hereby appoint the following individual as my health care power of attorney to make medical and treatment decisions on my behalf if I am unable to do so:
Name: ___________________________________________________
Relationship: ____________________________________________
Phone Number: ____________________________________________
If my primary agent is unable or unwilling to serve, I appoint the following individual as an alternate agent:
Name: ___________________________________________________
Relationship: ____________________________________________
Phone Number: ____________________________________________
Part 4: Signature
To ensure the directives stated in this Living Will are honored, it must be signed in the presence of two adult witnesses or a notary public, neither of whom is the appointed health care agent or alternate, a relative by blood, marriage, or adoption, or your attending physician.
Signature: _______________________________________________ Date: ________________
Witness 1 Signature: _______________________________________ Date: ________________
Witness 2 Signature: _______________________________________ Date: ________________