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Illinois ____________________ ______________ (Witness Signature) Print Name: ___________________________________________ _____________________________________________________ (Witness Signature) Print Name: _______________________nd belief, under any will of declarant or other instrument taking effect at declarant's death, or directly financially responsible for declarant's medical care. _______________________________________ection of the declarant. At the date of this instrument, I am not entitled to any portion of the estate of the declarant according to the laws of intestate succession or, to the best of my knowledge ad in my presence that he or she had signed the declaration) and I signed the declaration as a witness in the presence of the declarant. I did not sign the declarant's signature above for or at the dir____________________________ The declarant is personally known to me and I believe him or her to be of sound mind. I saw the declarant sign the declaration in my presence (or the declarant acknowledge treatment and accept the consequences from such refusal. Signed: __________________________________________________________________________ City, County and State of Residence _______________________ the use of such death delaying procedures, it is my intention that this declaration shall be honored by my family and physician as the final expression of my legal right to refuse medical or surgicaledication, sustenance, or the performance of any medical procedure deemed necessary by my attending physician to provide me with comfort care. In the absence of my ability to give directions regardingdeath delaying procedures, I direct that such procedures which would only prolong the dying process be withheld or withdrawn, and that I be permitted to die naturally with only the administration of mcurable and irreversible injury, disease, or illness judged to be a terminal condition by my attending physician who has personally examined me and has determined that my death is imminent except for __________________________________, being of sound mind, willfully and voluntarily make known my desires that my moment of death shall not be artificially postponed. If at any time I should have an insclaimers and Terms of Use found at findlegalforms.com Living Will DECLARATION This declaration is made this __________ day of _________________ , _________________(month, year). I, _________________aling with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Di starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommended when deir legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be aevocation. (Source: P.A. 85-860.) [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to theocation. (c) There shall be no criminal or civil liability on the part of any person for failure to act upon a revocation made pursuant to this Section unless that person has actual knowledge of the rcation. The attending physician shall record in the patient's Information & Instructions ­ Page 3 medical record the time and date when and the place where he or she received notification of the revnd dates a writing confirming that such expression of intent was made. (b) A revocation is effective upon communication to the attending physician by the declarant or by another who witnessed the revo or person acting at the direction of the declarant; or (3) By a oral or any other expression of the intent to revoke the declaration, in the presence of a witness 18 years of age or older who signs ads: (1) By being obliterated, burnt, torn or otherwise destroyed or defaced in a manner indicating intention to cancel; (2) By a written revocation of the declaration signed and dated by the declarant.A. 85-860.) 755 ILCS 35/5) Sec. 5. Revocation. (a) A declaration may be revoked at any time by the declarant, without regard to declarant's mental or physical condition, by any of the following method that his action violated the standard of reasonable professional care and judgment under the circumstances, he is immune from civil or criminal liability that otherwise might be incurred. (Source: P of the declaration in the declarant's medical record. A physician who records in writing a terminal condition under this Section is presumed to be acting in good faith. Unless it is alleged and proveSec. 4. Recording of a Terminal Condition. Upon determining that the declarant has a terminal condition, the attending physician who knows of a declaration shall record the determination and the termse patient to make such arrangements, (2) a guardian of the person of the patient, without the necessity of obtaining a court order to do so, and (3) any member of the patient's family. 755 ILCS 35/4) transfer of the patient and the appropriate medical records to another physician for the effectuation of the patient's declaration. The order of priority is as follows: (1) any person authorized by thansfer, then the attending physician shall without delay notify the person with the highest priority, as set forth in this subsection, who is available, able, and willing to make arrangements for the sibility to initiate the transfer to another physician of the patient's choosing. If the physician is unwilling to comply with its provisions and the patient is at any time not able to initiate the tring to comply with its provisions, the physician shall promptly so advise the declarant. If the physician is unwilling to comply with its provisions and the patient is able, it is the patient's respony with its provisions. An attending physician who is so notified shall make the declaration, or copy of the declaration, a part of the patient's medical records. If the physician is at any time unwillr notification to his or her attending physician of the existence of a declaration, to provide the declaration to the physician and to ask the attending physician whether he or she is willing to compl the fetus could develop to the point of live birth with the continued application of death delaying procedures. (d) If the patient is able, it shall be the responsibility of the patient to provide fo (c) The declaration of a qualified patient diagnosed as pregnant by the attending physician shall be given no force and effect as long as in the opinion of the attending physician it is possible thatnot be utilized for the prolongation of his life. (b) The declaration must be signed by the declarant, or another at the declarant's direction, and witnessed by 2 individuals 18 years of age or older.suant to the "Emancipation of Mature Minors Act", as now or hereafter amended, may execute a document directing that if he is suffering from a terminal condition, then death delaying procedures shall Source: P.A. 85-860.) (755 ILCS 35/3) Sec. 3. Execution of a Document. (a) An individual of sound mind and having reached the age of majority or having obtained the status of an emancipated person purrable and irreversible condition which is such that Information & Instructions ­ Page 2 death is imminent and the application of death delaying procedures serves only to prolong the dying process. (s personally examined the patient. A qualified patient has the right to make decisions regarding death delaying procedures as long as he or she is able to do so. (h) "Terminal condition" means an incupatient who has executed a declaration in accordance with this Act and who has been diagnosed and verified in writing to be afflicted with a terminal condition by his or her attending physician who haciation, government, governmental subdivision or agency, or any other legal entity. (f) ) "Physician" means a person licensed to practice medicine in all its branches. (g) "Qualified patient" means a result in death solely from dehydration or starvation rather than from the existing terminal condition. (e) "Person" means an individual, corporation, business trust, estate, trust, partnership, assoder to provide treatment for a patient's comfort care or alleviation of pain. Nutrition and hydration shall not be withdrawn or withheld from a qualified patient if the withdrawal or withholding woulde feeding and other procedures of greater or lesser magnitude that serve only to delay death. However, this Act does not affect the responsibility of the attending physician or other health care provi of death. In appropriate circumstances, such procedures include, but are not limited to, assisted ventilation, artificial kidney treatments, intravenous feeding or medication, blood transfusions, tub) "Death delaying procedure" means any medical procedure or intervention which, when applied to a qualified patient, in the judgement of the attending physician would serve only to postpone the momenth-care provider" means a person who is licensed, certified or otherwise authorized by the law of this State to administer health care in the ordinary course of business or practice of a profession. (dy for the treatment and care of the patient. (b) "Declaration" means a witnessed document in writing, voluntarily executed by the declarant in accordance with the requirements of Section 3. (c) "Healtf a terminal condition. (Source: P.A. 85-860.) (755 ILCS 35/2) Sec. 2. Definitions: (a) "Attending physician" means the physician selected by, or assigned to, the patient who has primary responsibilitclares that the laws of this State shall recognize the right of a person to make a written declaration instructing his or her physician to withhold or withdraw death delaying procedures in the event oances of a terminal condition. In order that the rights of patients may be respected even after they are no longer able to participate actively in decisions about themselves, the legislature hereby de persons have the fundamental right to control the decisions relating to the rendering of their own medical care, including the decision to have death delaying procedures withheld or withdrawn in inst Living Will Act (755 ILCS 35/). For your convenience, we have included useful excerpts from the Illinois Statutes relating to Living Wills. (755 ILCS 35/1) Sec. 1. Purpose. The legislature finds thation to Physicians (Illinois Living Will). This Illinois Declaration to Physicians (Illinois Living Will) is based on Chapter 755 Section 35 of the Illinois Compiled Statutes also known as the IllinoisInformation and Instructions Illinois Living Will Declaration This package contains (1) Information and Instruction for Illinois Declaration to Physicians (Illinois Living Will); (2) Illinois Declarat Illinois