West Virginia Living Will Template
This Living Will is designed to comply with the West Virginia Health Care Decisions Act and allows you to express your wishes regarding medical treatment in the event that you are unable to communicate your decisions. It is a legally binding document when properly filled out and executed according to the requirements of West Virginia law.
Part 1: Personal Information
Full Name: _________________________________________________________
Date of Birth: ________________________
Address: ___________________________________________________________
City: _________________________ State: WV Zip Code: ________________
Phone Number: _________________________
Part 2: Health Care Directives
This section allows you to make specific directives about your health care in the case that you are diagnosed with a terminal condition or are persistently unconscious and can no longer make decisions for yourself.
- Life-Prolonging Treatments: I do/do not (circle one) want life-prolonging treatments if I am diagnosed with a terminal condition or am persistently unconscious. Life-prolonging treatments include, but are not limited to, mechanical ventilation, resuscitation, and artificially provided nutrition and hydration.
- Pain Relief: Regardless of my decision regarding life-prolonging treatments, I wish to receive medication or other treatment necessary to relieve pain.
- Specific Instructions: _______________________________________________________________________________________________________________________________________.
Part 3: Health Care Power of Attorney
If you wish to appoint a Health Care Power of Attorney to make health care decisions for you in the event that you are unable to do so, complete the following:
Primary Health Care Agent:
Name: ______________________________________________________________
Relationship: _______________________________________________________
Phone Number: _________________________
Alternate Health Care Agent (if primary is unwilling or unable):
Name: ______________________________________________________________
Relationship: _______________________________________________________
Phone Number: _________________________
Part 4: Organ Donation
I do/do not (circle one) wish to donate my organs, tissues, and eyes upon my death. If I have marked "do," the following organs, tissues, and eyes may be donated for the purpose of transplantation, therapy, research, or education: _____________________________________________________.
Part 5: Signature
This Living Will becomes effective only when I cannot communicate my desires regarding medical treatment. By my signature below, I affirm that I am of sound mind and I understand the contents of this document, and I declare that I knowingly and voluntarily execute this Living Will.
Date: _________________________
Signature: _________________________________________________________
State of West Virginia, County of __________________: This document was acknowledged before me on (date) ______________ by (name of declarant) ___________________________________ who is personally known to me or has produced identification in the form of ________________________________________.
Notary Public: ______________________________________________________
My commission expires: _________________
Part 6: Witnesses
State law requires that this Living Will must be signed in the presence of two witnesses, who must also sign the document. Witnesses cannot be anyone who is entitled to any part of your estate upon your death under a will or by operation of law, or anyone who is responsible for your medical costs.
Witness 1: Name: ____________________________________________________
Relationship to Declarant: ___________________________________________
Witness 1 Signature: ___________________ Date: ______________________
Witness 2: Name: ____________________________________________________
Relationship to Declarant: ___________________________________________
Witness 2 Signature: ___________________ Date: ______________________