North Carolina Living Will
This Living Will is made pursuant to the laws of the state of North Carolina. It expresses my wishes regarding my medical treatment in the event that I become unable to communicate my preferences.
Personal Information
- Full Name: ______________________________________
- Date of Birth: ______________________________________
- Address: ______________________________________
- Phone Number: ______________________________________
Designation of Health Care Agent
If I am unable to make my own health care decisions, I appoint the following individual as my health care agent:
- Agent Name: ______________________________________
- Relationship: ______________________________________
- Contact Number: ______________________________________
Instructions
Please follow these instructions regarding my medical treatment:
- If I have a terminal condition and I am unable to make decisions, I do not want life-prolonging measures.
- If I am in a persistent vegetative state, I do not want artificial nutrition or hydration.
- I want my pain to be managed, even if it may hasten my death.
Additional Wishes
Additional instructions and preferences are as follows:
____________________________________________________________________
____________________________________________________________________
Signatures
I, ____________________________________, sign this Living Will in the presence of the witnesses below:
Date: ______________________________________
Witnesses
- _______________________________ (Print Name) - ____________________________ (Signature)
- _______________________________ (Print Name) - ____________________________ (Signature)
This Living Will reflects my wishes and should be followed as such. Thank you for respecting my decisions.