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Illinois ______________ _____________________________________________________ (Witness Signature) Print Name: ___________________________________________ declarant's death, or directly financially responsible for declarant's medical care. _____________________________________________________ (Witness Signature) Print Name: _____________________________o any portion of the estate of the declarant according to the laws of intestate succession or, to the best of my knowledge and belief, under any will of declarant or other instrument taking effect at declaration as a witness in the presence of the declarant. I did not sign the declarant's signature above for or at the direction of the declarant. At the date of this instrument, I am not entitled telieve him or her to be of sound mind. I saw the declarant sign the declaration in my presence (or the declarant acknowledged in my presence that he or she had signed the declaration) and I signed the______________________________________________________________ City, County and State of Residence ___________________________________________________ The declarant is personally known to me and I bation shall be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal. Signed: ____________sary by my attending physician to provide me with comfort care. In the absence of my ability to give directions regarding the use of such death delaying procedures, it is my intention that this declarng the dying process be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, sustenance, or the performance of any medical procedure deemed necesndition by my attending physician who has personally examined me and has determined that my death is imminent except for death delaying procedures, I direct that such procedures which would only proloily make known my desires that my moment of death shall not be artificially postponed. If at any time I should have an incurable and irreversible injury, disease, or illness judged to be a terminal co This declaration is made this __________ day of _________________ , _________________(month, year). I, ___________________________________________________, being of sound mind, willfully and voluntarf this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Living Will DECLARATIONattorney first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out osubstitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an mplied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a erson for failure to act upon a revocation made pursuant to this Section unless that person has actual knowledge of the revocation. (Source: P.A. 85-860.) [_] These forms are provided "as is" and no istructions ­ Page 3 medical record the time and date when and the place where he or she received notification of the revocation. (c) There shall be no criminal or civil liability on the part of any peffective upon communication to the attending physician by the declarant or by another who witnessed the revocation. The attending physician shall record in the patient's Living Will Information & Inon of the intent to revoke the declaration, in the presence of a witness 18 years of age or older who signs and dates a writing confirming that such expression of intent was made. (b) A revocation is icating intention to cancel; (2) By a written revocation of the declaration signed and dated by the declarant or person acting at the direction of the declarant; or (3) By a oral or any other expressie by the declarant, without regard to declarant's mental or physical condition, by any of the following methods: (1) By being obliterated, burnt, torn or otherwise destroyed or defaced in a manner indthe circumstances, he is immune from civil or criminal liability that otherwise might be incurred. (Source: P.A. 85-860.) 755 ILCS 35/5) Sec. 5. Revocation. (a) A declaration may be revoked at any tim terminal condition under this Section is presumed to be acting in good faith. Unless it is alleged and proved that his action violated the standard of reasonable professional care and judgment under al condition, the attending physician who knows of a declaration shall record the determination and the terms of the declaration in the declarant's medical record. A physician who records in writing ahe necessity of obtaining a court order to do so, and (3) any member of the patient's family. 755 ILCS 35/4) Sec. 4. Recording of a Terminal Condition. Upon determining that the declarant has a terminfectuation of the patient's declaration. The order of priority is as follows: (1) any person authorized by the patient to make such arrangements, (2) a guardian of the person of the patient, without t priority, as set forth in this subsection, who is available, able, and willing to make arrangements for the transfer of the patient and the appropriate medical records to another physician for the efysician is unwilling to comply with its provisions and the patient is at any time not able to initiate the transfer, then the attending physician shall without delay notify the person with the highest the physician is unwilling to comply with its provisions and the patient is able, it is the patient's responsibility to initiate the transfer to another physician of the patient's choosing. If the ph, or copy of the declaration, a part of the patient's medical records. If the physician is at any time unwilling to comply with its provisions, the physician shall promptly so advise the declarant. Ifide the declaration to the physician and to ask the attending physician whether he or she is willing to comply with its provisions. An attending physician who is so notified shall make the declaration delaying procedures. (d) If the patient is able, it shall be the responsibility of the patient to provide for notification to his or her attending physician of the existence of a declaration, to provn shall be given no force and effect as long as in the opinion of the attending physician it is possible that the fetus could develop to the point of live birth with the continued application of death declarant, or another at the declarant's direction, and witnessed by 2 individuals 18 years of age or older. (c) The declaration of a qualified patient diagnosed as pregnant by the attending physiciaa document directing that if he is suffering from a terminal condition, then death delaying procedures shall not be utilized for the prolongation of his life. (b) The declaration must be signed by the sound mind and having reached the age of majority or having obtained the status of an emancipated person pursuant to the "Emancipation of Mature Minors Act", as now or hereafter amended, may execute eath is imminent and the application of death delaying procedures serves only to prolong the dying process. (Source: P.A. 85-860.) (755 ILCS 35/3) Sec. 3. Execution of a Document. (a) An individual ofdelaying procedures as long as he or she is able to do so. (h) "Terminal condition" means an incurable and irreversible condition which is such that Living Will Information & Instructions ­ Page 2 died in writing to be afflicted with a terminal condition by his or her attending physician who has personally examined the patient. A qualified patient has the right to make decisions regarding death eans a person licensed to practice medicine in all its branches. (g) "Qualified patient" means a patient who has executed a declaration in accordance with this Act and who has been diagnosed and verif. (e) "Person" means an individual, corporation, business trust, estate, trust, partnership, association, government, governmental subdivision or agency, or any other legal entity. (f) ) "Physician" mhall not be withdrawn or withheld from a qualified patient if the withdrawal or withholding would result in death solely from dehydration or starvation rather than from the existing terminal conditionthis Act does not affect the responsibility of the attending physician or other health care provider to provide treatment for a patient's comfort care or alleviation of pain. Nutrition and hydration silation, artificial kidney treatments, intravenous feeding or medication, blood transfusions, tube feeding and other procedures of greater or lesser magnitude that serve only to delay death. However, fied patient, in the judgement of the attending physician would serve only to postpone the moment of death. In appropriate circumstances, such procedures include, but are not limited to, assisted venttate to administer health care in the ordinary course of business or practice of a profession. (d) "Death delaying procedure" means any medical procedure or intervention which, when applied to a qualioluntarily executed by the declarant in accordance with the requirements of Section 3. (c) "Health-care provider" means a person who is licensed, certified or otherwise authorized by the law of this Sician" means the physician selected by, or assigned to, the patient who has primary responsibility for the treatment and care of the patient. (b) "Declaration" means a witnessed document in writing, vinstructing his or her physician to withhold or withdraw death delaying procedures in the event of a terminal condition. (Source: P.A. 85-860.) (755 ILCS 35/2) Sec. 2. Definitions: (a) "Attending physe no longer able to participate actively in decisions about themselves, the legislature hereby declares that the laws of this State shall recognize the right of a person to make a written declaration ical care, including the decision to have death delaying procedures withheld or withdrawn in instances of a terminal condition. In order that the rights of patients may be respected even after they aris Statutes relating to Living Wills. (755 ILCS 35/1) Sec. 1. Purpose. The legislature finds that persons have the fundamental right to control the decisions relating to the rendering of their own med) is based on Chapter 755 Section 35 of the Illinois Compiled Statutes also known as the Illinois Living Will Act (755 ILCS 35/). For your convenience, we have included useful excerpts from the Illino Instruction for Illinois Declaration to Physicians (Illinois Living Will); (2) Illinois Declaration to Physicians (Illinois Living Will). This Illinois Declaration to Physicians (Illinois Living Will______________________________ (Successor agent) _________________________________ (Principal) Information and Instructions Illinois Living Will Declaration This package contains (1) Information andgnature of my agent (and successors) are correct. _________________________________ (Principal) _________________________________ (Successor agent) _________________________________ (Principal) ___of attorney, you must complete the certification opposite the signatures of the agents.) Specimen signatures of agent (and successors) _________________________________ (Agent) I certify that the si__________________________ (witness) (You may, but are not required to, request your agent and successor agents to provide specimen signatures below. If you include specimen signatures in this power principal has had an opportunity to read the above form and has signed the form or acknowledged his or her signature or mark on the form in my presence. _______________________________ Residing at __ of this grant of powers to my agent. Illinois Statutory Short Form Power of Attorney for Health Care Page 4 Signed: _______________________________________________________________ (principal) The I nominate the agent acting under this power of attorney as such guardian, to serve without bond or security. 7. I am fully informed as to all the contents of this form and understand the full importourt finds that such appointment will serve your best interests and welfare. Strike out paragraph 6 if you do not want your agent to act as guardian.) 6. If a guardian of my person is to be appointed,dian of your person, in the event a court decides that one should be appointed, you may, but are not required to, do so by retaining the following paragraph. The court will appoint your agent if the cncompetent or disabled person or the person is unable to give prompt and intelligent consideration to health care matters, as certified by a licensed physician. (If you wish to name your agent as guar________________________________________________________________ For purposes of this paragraph 5, a person shall be considered to be incompetent if and while the person is a minor or an adjudicated ithe order named) as successors to such agent: ________________________________________________________________________ ________________________________________________________________________ ________ing paragraph.) 5. If any agent named by me shall die, become incompetent, resign, refuse to accept the office of agent or be unavailable, I name the following (each to act alone and successively, in rt determination of your disability, when you want this power to terminate prior to your death.) (If you wish to name successor agents, insert the names and addresses of such successors in the followfect) 4. ( ) This power of attorney shall terminate on ______________________________ _____________________________________________________________________ (Insert a future date or event, such as cou_________________________________________________________ (insert a future date or event during your lifetime, such as court determination of your disability, when you want this power to first take ef on the beginning date or duration is made by initialing and completing either or both of the following:) 3. ( ) This power of attorney shall become effective ___________________________ _____________ attorney will become effective at the time this power is signed and will continue until your death, and beyond if anatomical gift, autopsy or disposition of remains is authorized, unless a limitationy you in the manner provided in section 4-6 of the Illinois "powers of attorney for health care law" (see the back of this form). Absent amendment or revocation, the authority granted in this power ofI have for recovery or the cost of the procedures. Initialed _____________ Illinois Statutory Short Form Power of Attorney for Health Care Page 3 (This power of attorney may be amended or revoked bma, I want life-sustaining treatment to be withheld or discontinued. Initialed _____________ I want my life to be prolonged to the greatest extent possible without regard to my condition, the chances ed unless I am in a coma which my attending physician believes to be irreversible, in accordance with reasonable medical standards at the time of reference. If and when I have suffered irreversible coble extension of my life in making decisions concerning life-sustaining treatment. Initialed _____________ I want my life to be prolonged and I want life-sustaining treatment to be provided or continuntinued if my agent believes the burdens of the treatment outweigh the expected benefits. I want my agent to consider the relief of suffering, the expense involved and the quality as well as the possigree with one of these statements, you may initial that statement; but do not initial more than one): I do not want my life to be prolonged nor do I want life-sustaining treatment to be provided or cois of particular importance. For your convenience in dealing with that subject, some general statements concerning the withholding or removal of life-sustaining treatment are set forth below. If you astitution, etc.): _____________________________________________________________________ _____________________________________________________________________ (The subject of life-sustaining treatment consistent with your religious beliefs or unacceptable to you for any other reason, such as blood transfusion, electro-convulsive therapy, amputation, psychosurgery, voluntary admission to a mental inn life-sustaining measures should be withheld; a direction to continue food and fluids or life-sustaining treatment in all events; or instructions to refuse any specific types of treatment that are inhall not include the following powers or shall be subject to the following rules or limitations (here you may include any specific limitations you deem appropriate, such as: your own definition of whet's powers or prescribe special rules or limit the power to make an anatomical gift, authorize autopsy or dispose of remains, you may do so in the following paragraphs.) 2. The powers granted above sluding withdrawal of food and water and other life-sustaining measures, if your agent believes such action would be consistent with your intent and desires. If you wish to limit the scope of your agen Page 2 (The above grant of power is intended to be as broad as possible so that your agent will have authority to make any decision you could make to obtain or terminate any type of health care, incific organs: __________________________________________________ ______________________________________________________________________ Illinois Statutory Short Form Power of Attorney for Health Care orize an autopsy and direct the disposition of my remains. Effective upon my death, my agent has the full power to make an anatomical gift of the following (initial one): ______ Any organ: ______ Specen though my death may ensue. My agent shall have the same access to my medical records that I have, including the right to disclose the contents to others. My agent shall also have full power to authto make any and all decisions for me concerning my personal care, medical treatment, hospitalization and health care and to require, withhold or withdraw any type of medical treatment or procedure, ev_____________________________________________________________ (insert name and address of agent) as my attorney- in- fact (my "agent") to act for me and in my name (in any way I could act in person) made this __________ day of___________________(month, year). 1. I, __________________________________________________________________ (insert name and address of principal) hereby appoint: __________ts the use of any different form of power of attorney you may desire. If there is anything about this form that you do not understand, you should ask a lawyer to explain it to you.) POWER OF ATTORNEY ies for violating the law are explained more fully in sections 4-5, 4-6, 4-9 and 4-10(b) of the Illinois "Powers of Attorney for Health Care Law" of which this form is a part. That law expressly permi terminates it, your agent may exercise the powers given here throughout your lifetime, even after you become disabled. The powers you give your agent, your right to revoke those powers and the penaltot co-agents, and no health care provider may be named. Unless you expressly limit the duration of this power in the manner provided below, until you revoke this power or a court acting on your behalfipts, disbursements and significant actions taken as agent. A court can take away powers of your agent if it finds the agent is not acting properly. You may name successor agents under this form but n a duty on your agent to exercise granted powers; but when powers are exercised, your agent will have to use due care to act for your benefit and in accordance with this form and keep a record of receithdraw any type of personal care or medical treatment for any physical or mental condition and to admit you to or discharge you from any hospital, home or other institution. This form does not imposeh Care (NOTICE: the purpose of this power of attorney is to give the person you designate (your "agent") broad powers to make health care decisions for you, including power to require, consent to or wd with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Illinois Statutory Short Form Power of Attorney for Healts your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussevice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fitbeen made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax ade Health Care Directive. The first form is the Power of Attorney for Health Care and the second form is the Living Will. [_] These forms are provided "as is" and no implied or express warranties have Illinois Advance Health Care Directive This package contains both an Illinois Power of Attorney for Health Care and an Illinois Living Will. Together these forms are also sometimes known as an Advanc Illinois