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Ohio __________________________ (Notary Public) 4 executed the same for the purposes expressed therein. I attest that the Declarant appears to be of sound mind and not under or subject to duress, fraud or undue influence. My Commission Expires: ___________________________________, (Name of Declarant) known to me or satisfactorily proven to be the Declarant whose name is subscribed to the above Living Will Declaration, and acknowledged that (s)heState of Ohio County of _______________________________, S.S.: On this the ____________ day of _______________________, 20 _______, before me, the undersigned Notary Public, personally appeared ___________________ (Witness 2 Signature) Print Name: ___________________________________ Address: ______________________________________ Date: _________________________________________ OR ACKNOWLEDGEMENT (Witness 1 Signature) Print Name: ___________________________________ Address: ______________________________________ Date: _________________________________________ ________________________________nistrator of a nursing home in which the Declarant is receiving care, and that I am an adult not related to the Declarant by blood, marriage, or adoption. _____________________________________________ that the Declarant appears to be of sound mind and not under or subject to duress, fraud or undue influence. I further attest that I am not the attending physician of the Declarant, I am not the admi_______________ (city), Ohio. __________________________________________ (Declarant's Signature) 3 I attest that the Declarant signed or acknowledged this Living Will Declaration in my presence, andence pain or suffering. I understand the purpose and effect of this document and sign my name to this Living Will Declaration after careful deliberation on _______________, (date) at _________________rized by both of the following: (1) I am irreversibly unaware of myself and my Environment, and (2) There is a total loss of cerebral cortical functioning, resulting in my having no capacity to experisness that, to a reasonable Degree of medical certainty as determined in Accordance with reasonable medical standards by My attending physician and one other physician who Has examined me, is characteno recovery, and (2) death is likely to occur within a relatively short time if life-sustaining treatment is not Administered. (c) "permanently unconscious state" means a state of Permanent unconsciouof medical certainty as determined in Accordance with reasonable medical standards by my attending physician and one other physician who has examined me, both of the following apply: (1) there can be ncipally to prolong the process of dying. (B) "terminal condition" means an irreversible, Incurable, and untreatable condition caused by Disease, illness, or injury from which, to a reasonable Degree ing treatment" means any medical procedure, treatment, intervention, or other measure including artificially or technologically supplied nutrition and hydration that, when administered, will serve pri____________________________________________________________ Work Phone: _______________________________________________________________ For purposes of this Living Will Declaration: (A) "Life-sustain_______________________________ Address: __________________________________________________________________ ______________________________________ Zip Code: ___________________________ Home Phone: ___ Work Phone: _______________________________________________________________ Name 2: ____________________________________________________________________ Relationship: ___________________________________________________________________________ ______________________________________ Zip Code: ___________________________ Home Phone: _______________________________________________________________ 2r of priority: Name 1: ____________________________________________________________________ Relationship: ______________________________________________________________ Address: ______________________nes that life-sustaining treatment should be withheld or withdrawn, he or she shall make a good faith effort and use reasonable diligence to notify one of the persons named below in the following orde__ ____________________________________________________________________________ ____________________________________________________________________________ In the event my attending physician determi________________________________________________ ____________________________________________________________________________ __________________________________________________________________________BLE MEDICAL STANDARDS, THAT SUCH NUTRITION OR HYDRATION WILL NOT OR NO LONGER WILL SERVE TO PROVIDE COMFORT TO ME OR ALLEVIATE MY PAIN. Additional Instructions (optional): ____________________________A PERMANENTLY UNCONSCIOUS STATE AND IF MY ATTENDING PHYSICIAN AND AT LEAST ONE OTHER PHYSICIAN WHO HAS EXAMINED ME DETERMINE, TO A REASONABLE DEGREE OF MEDICAL CERTAINTY AND IN ACCORDANCE WITH REASONARIZE MY ATTENDING PHYSICIAN TO WITHHOLD,OR IN THE EVENT THAT TREATMENT HAS ALREADY COMMENCED, TO WITHDRAW THE PROVISION OF ARTIFICIALLY OR TECHNOLOGICALLY SUPPLIED NUTRITION AND HYDRATION, IF I AM IN ry to make me comfortable and to relieve my pain but not to postpone my death. __________ IN ADDITION, IF I HAVE MARKED THE FOREGOING BOX AND HAVE PLACED MY INITIALS ON THE LINE ADJACENTTO IT, I AUTHOwing paragraph, I have authorized its withholding or withdrawal; · withdraw such treatment if such treatment has commenced; and, · permit me to die naturally and provide me with only that care necessairect that my attending physician shall: 1 · administer no life-sustaining treatment, except for the provision of artificially or technologically supplied nutrition or hydration unless, in the follo naturally and provide me with only the care necessary to make me comfortable and to relieve my pain but not to postpone my death. In the event I am in a permanently unconscious state, I declare and dondition, I declare and direct that my attending physician shall: · administer no life-sustaining treatment; · withdraw life-sustaining treatment if such treatment has commenced; and, permit me to dierefuse medical or surgical treatment. I am a competent adult who understands and accepts the consequences of such refusal and the purpose and effect of this document. In the event I am in a terminal ca terminal condition or a permanently unconscious state, it is my intention that this Living Will Declaration shall be honored by my family and physicians as the final expression of my legal right to Ohio Revised Code, do voluntarily make known my desire that my dying shall not be artificially prolonged. If I am unable to give directions regarding the use of life-sustaining treatment when I am in ____________________________, (address) Ohio, being of sound mind and not subject to duress, fraud or undue influence, intending to create a Living Will Declaration under Chapter 2133 et. Seq. of the ring a Durable Power of Attorney for Health Care. Declaration I, ___________________________________________________________, (name of Declarant) presently residing at ________________________________aration may be relied on only for individuals in a terminal condition or a permanently unconscious state. If you wish to direct your medical treatment in other circumstances, you should consider prepa sustaining treatment, you have the legal right to so choose and you might want to state your medical treatment preferences in writing in another form of Declaration. Under Ohio law a Living Will Declheld or withdrawn if the individual is unable to communicate and is in a terminal condition or a permanently unconscious state. If you would choose not to withhold or withdraw any or all forms of life Will Declaration is designed to serve as evidence of an individual's desire that life-sustaining medical treatment, including artificially or technologically supplied nutrition and hydration, be with tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Living Will DECLARATION Notice to Declarant This form of a Livingarticular 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 discussed with aws 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 fits your pe 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 advice. Lan. As used in this section, "DNR identification" has the same meaning as in section 2133.21 of the Revised Code. [_] These forms are provided "as is" and no implied or express warranties have been madmaking any other type of designation, except that the printed form may be used as a DNR identification if the declarant specifies on the form that the declarant wishes to use it as a DNR identificatioany time that life-sustaining treatment would be withheld or withdrawn pursuant to the declaration. The printed form shall not be used as an instrument for granting any other type of authority or for tions ­ Page 5 state as described in division (A)(3)(a) of section 2133.02 of the Revised Code, and may designate one or more persons who are to be notified by the declarant's attending physician at terminal condition or a permanently unconscious state, may authorize the withholding or withdrawal of nutrition or hydration should the declarant be in a permanently unconscious Information & Instrucant may authorize the use or continuation, or the withholding or withdrawal, of life-sustaining treatment should the declarant be in a terminal condition, a permanently unconscious state, or either a printed form. A printed form of a declaration may be sold or otherwise distributed in this state for use by adults who are not advised by an attorney. By use of a printed form of that nature, a declaren revoked, the attending physician or other health care personnel acting under the direction of the attending physician shall make the fact a part of the declarant's medical record. § 2133.07 Use of ion and act in accordance with the revocation. (B) Upon the communication as described in division (A) of this section to the attending physician of a declarant of the fact that his declaration has beual knowledge to the contrary, the attending physician of a declarant and other health care personnel who are informed of the revocation of a declaration by an alleged witness may rely on the informatn to the attending physician of the declarant by the declarant himself, a witness to the revocation, or other health care personnel to whom the revocation is communicated by such a witness. Absent acteclarant expresses his intention to revoke the declaration, except that, if the declarant made his attending physician aware of the declaration, the revocation shall be effective upon its communicatiorsuant to section 2133.04 of the Revised Code. § 2133.04 Revocation of declaration. (A) A declarant may revoke a declaration at any time and in any manner. The revocation shall be effective when the dents would conflict if the declarant should be in a terminal condition or in a permanently unconscious state. Division (B)(2) of this section does not apply if the declarant revokes the declaration pu both a valid durable power of attorney for health care and a valid declaration, the declaration supersedes the durable power of attorney for health care to the extent that the provisions of the docum upon a do-not-resuscitate order, as defined in section 2133.21 of the Revised Code, that a physician has issued for the declarant and that is inconsistent with the declaration. (2) If a declarant hasA declaration supersedes a DNR identification, as defined in section 2133.21 of the Revised Code, of the declarant that is based upon a prior inconsistent declaration of the declarant or that is based declarant. Division (B)(1)(a) of this section does not apply if a declaration is revoked pursuant to section 2133.04 of the Revised Code after the signing of a general consent to treatment form. (b) s ­ Page 4 or continuation, or the withholding or withdrawal, of life-sustaining treatment and other medical or nursing procedures, treatments, interventions, or other measures in connection with theexecution of the declaration. To the extent that the provisions of a declaration and a general consent to treatment form do not conflict, both documents shall govern the use Information & Instructionthe declarant prior to, upon, or after the declarant's admission to a health care facility to the extent there is a conflict between the declaration and the form, even if the form is signed after the n the capacity to make informed decisions regarding the administration of life-sustaining treatment. (B)(1)(a) A declaration supersedes any general consent to treatment form signed by or on behalf of shall determine, in good faith, to a reasonable degree of medical certainty, and in accordance with reasonable medical standards, that there is no reasonable possibility that the declarant will regai state. (3) In order for a declaration to become operative in connection with a declarant who is in a terminal condition or in a permanently unconscious state, the attending physician of the declaranticine and surgery, or of experience acquired in the practice of medicine or surgery or osteopathic medicine and surgery, is qualified to determine whether the declarant is in a permanently unconsciousllnesses, injuries, therapies, or branches of medicine or surgery or osteopathic medicine and surgery, of certification as a specialist in a particular branch of medicine or surgery or osteopathic medwith the determination that the declarant is in the permanently unconscious state shall be a physician who, by virtue of advanced education or training, of a practice limited to particular diseases, if section 2133.10 of the Revised Code. (2) In order for a declaration to become operative in connection with a declarant who is in a permanently unconscious state, the consulting physician associated ion of life-sustaining treatment. When the declaration becomes operative, the attending physician and health care facilities shall act in accordance with its provisions or comply with the provisions orequirements of divisions (A)(2) and (3) of this section are satisfied, and the attending physician determines that the declarant no longer is able to make informed decisions regarding the administratone other physician who examines the declarant determine that the declarant is in a terminal condition or in a permanently unconscious state, whichever is addressed in the declaration, the applicable NR identification or durable power of attorney for health care. (A)(1) A declaration becomes operative when it is communicated to the attending physician of the declarant, the attending physician and (E) As used in this section, "CPR" has the same meaning as in section 2133.21 of the Revised Code. § 2133.03 When declaration becomes operative; declaration supersedes general consent to treatment, D Revised Code, or, if the declaration has become operative as described in division (A) of section 2133.03 of the Revised Code, shall comply with the provisions of section 2133.10 of the Revised Code.ng or not able to comply or allow compliance with the declarant's declaration, the physician or facility promptly shall so advise the declarant and comply with the provisions of section 2133.10 of theation on the basis of a matter of conscience. Information & Instructions ­ Page 3 (2) If an attending physician of a declarant or a health care facility in which a declarant is confined is not willicience or on another basis. An employee or agent of an attending physician of a declarant or of a health care facility in which a declarant is confined may refuse to comply with the declarant's declarattending physician of a declarant or a health care facility in which a declarant is confined may refuse to comply or allow compliance with the declarant's declaration on the basis of a matter of consake it a part of the declarant's medical record and, when section 2133.05 of the Revised Code is applicable, also shall comply with that section. (D)(1) Subject to division (D)(2) of this section, an to duress, fraud, or undue influence. (C) An attending physician, or other health care personnel acting under the direction of an attending physician, who is furnished a copy of a declaration shall md before a notary public, who shall make the certification described in section 147.53 of the Revised Code and also shall attest that the declarant appears to be of sound mind and not under or subjectf the witnesses under this division are not required to appear on the same page of the declaration. (2) If acknowledged for purposes of division (A) of this section, a declaration shall be acknowledgesound mind and not under or subject to duress, fraud, or undue influence. The signatures of the declarant or other individual at the direction of the declarant under division (A) of this section and oe the witness' signature after the signature of the declarant or other individual at the direction of the declarant and, by doing so, attest to the witness' belief that the declarant appears to be of marriage, or adoption, who are not the attending physician of the declarant, and who are not the administrator of any nursing home in which the declarant is receiving care. Each witness shall subscrib presence the declarant, or another individual at the direction of the declarant, signed the declaration. The witnesses to a declaration shall be adults who are not related to the declarant by blood, ply to a declarant in a terminal condition. (B)(1) If witnessed for purposes of division (A) of this section, a declaration shall be witnessed by two individuals as described in this division in whoseolding or withdrawal of life-sustaining treatment when a declarant is in a terminal condition. The provisions of division (E) of section 2133.12 of the Revised Code pertaining to comfort care shall apt to the statement, check, or other mark described in division (A)(3)(a)(i) of this section. (b) Division (A)(3)(a) of this section does not apply to the extent that a declaration authorizes the withhain, or checking or otherwise marking a box or line that is adjacent to a similar statement on a printed form of a declaration; (ii) Placing the declarant's initials or signature underneath or adjacenf medical certainty and in accordance with reasonable medical standards, that nutrition or hydration will not or no longer will serve to provide comfort to the declarant or alleviate the declarant's pon if the declarant is in a permanently unconscious state and if the declarant's attending physician and at least one other physician who has examined the declarant determine, to a reasonable degree oding, but not limited to, a different font, bigger type, or boldface type, that the declarant's attending Information & Instructions ­ Page 2 physician may withhold or withdraw nutrition and hydratior hydration when the declarant is in the permanently unconscious state by doing both of the following in the declaration: (i) Including a statement in capital letters or other conspicuous type, incluor no longer will serve to provide comfort to the declarant or alleviate the declarant's pain, then the declarant shall authorize the declarant's attending physician to withhold or withdraw nutrition ent intends that the declarant's attending physician withhold or withdraw nutrition or hydration when the declarant is in a permanently unconscious state and when the nutrition and hydration will not n a manner that is substantially consistent with the provisions of section 2133.01 of the Revised Code. (3)(a) If a declarant who has authorized the withholding or withdrawal of life-sustaining treatmnently unconscious state, the declarant's declaration shall use either or both of the terms "terminal condition" and "permanently unconscious state" and shall define or otherwise explain those terms i2) Depending upon whether the declarant intends the declaration to apply when the declarant is in a terminal condition, in a permanently unconscious state, or in either a terminal condition or a permaion for the withholding or withdrawal of CPR does not preclude the withholding or withdrawal of CPR in accordance with sections 2133.01 to 2133.15 or sections 2133.21 to 2133.26 of the Revised Code. ( pursuant to the declaration. The declaration may include a specific authorization for the use or continuation or the withholding or withdrawal of CPR, but the failure to include a specific authorizatay include a designation by the declarant of one or more persons who are to be notified by the declarant's attending physician at any time that life-sustaining treatment would be withheld or withdrawndate of its execution, and either be witnessed as described in division (B)(1) of this section or be acknowledged by the declarant in accordance with division (B)(2) of this section. The declaration mtion, or the withholding or withdrawal, of life-sustaining treatment. The declaration shall be signed at the end by the declarant or by another individual at the direction of the declarant, state the tion, or withholding or withdrawal, of lifesustaining treatment; refusal to comply. (A)(1) An adult who is of sound mind voluntarily may execute at any time a declaration governing the use or continuaSection 2133.01 et. Seq. of the Ohio Revised Code. For your convenience, we have included useful excerpts from the Ohio Statutes relating to Living Wills. 2133.02 Declaration governing use or continuaInformation and Instructions Ohio Living Will This package contains (1) Information and Instruction for Ohio Living Will; (2) Ohio Living Will. This Ohio Living Will is based on Title 21 Chapter 2133 Ohio