North Carolina Living Will
This Living Will is designed to reflect the wishes of the undersigned, or the Principal, regarding their medical treatment preferences in circumstances where they are no longer able to communicate their decisions due to incapacity. It is created in accordance with the North Carolina General Statutes, Article 23 - Right to Natural Death; Life-Prolonging Measures.
Principal Information
Full Name: ____________________________________________
Date of Birth: _________________________________________
Address: ______________________________________________
City: ______________________ State: NC Zip: ___________
Phone Number: _________________________________________
Declaration
I, _____________________________, being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, and I declare:
- If at any time I should have an incurable or irreversible condition that will cause my death within a relatively short time, and I am no longer able to make decisions regarding my medical treatment, I direct that my health care providers withhold or withdraw treatment that only prolongs the dying process and is not necessary to my comfort or to alleviate pain.
- I desire that my life not be prolonged by life-prolonging measures if my condition is terminal and incurable or if I am in a persistent vegetative state. I further direct that treatment be limited to measures needed to maintain my comfort and relieve pain, including any pain that might result from the lack of treatment.
- In the absence of my ability to give directions regarding the use of life-prolonging measures, it is my intention that this directive shall be honored by my family and physicians as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences of such refusal.
- I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration.
Signatures
Signature of Principal: _______________________________ Date: ____________
State of North Carolina
County of ________________________
This document was acknowledged before me on (date) ______________ by (name of principal) ________________________________.
Signature of Notary Public: ____________________________
Name of Notary: _______________________________________ Printed
My commission expires: ____________
Witnesses
First Witness Signature: _______________________________ Date: ____________
Print Name: ___________________________________________
Second Witness Signature: _____________________________ Date: ____________
Print Name: ___________________________________________
Special Directives or Limitations
(Here, you may include any specific directives or limitations concerning your health care that you wish to have followed. This section can address concerns such as preferences for hospice care, organ donation preferences, and whether you would prefer to die at home, if possible. Use additional sheets if necessary.)
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This document reflects the wishes of the Principal with respect to their medical treatment at a time when they may no longer be able to communicate their wishes themselves. It is recommended that this document be reviewed periodically to ensure that it continues to reflect your current desires.