Advance Directive for a Natural Death ("Living Will")

Your First and Last Name *

First

Last

We'd like to know what to call you.

previous in instrument,

Full Legal Name of Person Making Advance Directive *

Provide your full legal name exactly as you would want it on important legal documents.

Current Mailing Address of Person Making the Directive *

Address Line 1

Address Line 2

City

State

Zip Code

My directions about prolonging my life shall apply IF my attending physician determines that I lack capacity to make or communicate health care decisions and: *

I have an incurable or irreversible condition that will result in my death within a relatively short period of time.
I become unconscious and my health care providers determine that, to a high degree of medical certainty, I will never regain my consciousness.
I suffer from advanced dementia or any other condition which results in the substantial loss of my cognitive ability and my health care providers determine that, to a high degree of medical certainty, this loss is not reversible.

North Carolina law provides that your medical provider shall, subject to limited exceptions, follow an advance directive for a natural death which directs the withdrawal of life prolonging measures under the one the situations above.

In those situations I have checked in the previous response, I direct that my health care providers: *

may withhold or withdraw life-prolonging measures.
shall withhold or withdraw life-prolonging measures.

You may give permission to withdraw life-prolonging measures, or you may leave an instruction to withdraw life-prolonging measures

Would you like to make an exception and still receive either Artifical Hydration or Artificial Nutrition? *

I DO NOT want to make an exception for artificial hydration or artificial nutrition.
I DO want to receive BOTH artificial hydration AND artificial nutrition (for example, through tubes) in those situations.
I DO want to receive ONLY artificial hydration (for example, through tubes) in those situations.
I DO want to receive ONLY artificial nutrition (for example, through tubes) in those situations.

While we do not intend to give you legal advice to complete this form, we do recommend you research this question thoroughly. To start, we recommend the following article: https://hoplerwilms.com/artificialnutritionhydration

If I have appointed a health care agent by executing a health care power of attorney or similar instrument, and that health care agent is acting and available and gives instructions that differ from this Advance Directive, then I direct that:

this Advance Directive will override instructions my health care agent gives about prolonging my life.
my health care agent has authority to override this Advance Directive.

In the event of a conflict between what your designated agent instructs and what you have left as an instruction in this instrument, tell us what instructions the medical provider should follow.

Email to Send the Advance Directive for a Natural Death *

We send you the document in PDF format. For a PDF Reader: https://www.adobe.com/acrobat/pdf-reader.html

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Advance Directive for a Natural Death (“Living Will”)