Kentucky Living Will Template
This Kentucky Living Will Template is created in accordance with the Kentucky Living Will Directive Act (Kentucky Revised Statutes, Chapter 311.621-311.643). It is designed to enable you (the "Principal") to declare your wishes regarding the use of life-prolonging treatment in the event that you are diagnosed with a terminal condition or enter a persistent vegetative state and are unable to communicate your healthcare decisions.
Principal’s Information:
Full Name: _______________________________________________
Date of Birth: ___________________________________________
Address: _________________________________________________
Directive Statement:
I, _________________, being of sound mind and legal age, hereby declare my directives regarding my healthcare. If at any time I am unable to communicate my healthcare decisions and am diagnosed with a terminal condition or am in a persistent vegetative state, I direct the following (check one or both, as desired):
- The withholding or withdrawal of life-prolonging treatment that merely prolongs the process of dying and is not curative or solely for comfort care.
- The provision of all available medical treatments, regardless of my condition or chances of recovery, with the intent of prolonging my life as long as medically possible.
Signatures:
___________________________ ___________________________
Principal’s Signature Date
___________________________ ___________________________
Witness’s Signature Date
This document is signed in the presence of two witnesses, who are not the spouse, next of kin, anyone entitled to any part of the estate of the person under any will or codicil thereto or any trust, an attending physician, or an employee of an attending physician or a health facility in which the declarant is a patient.
Notarization (Optional but Recommended):
This document was notarized on __________________ (date) by _______________________________________________ (Notary Public), in the state of Kentucky.
Disclosure Statement to Healthcare Providers:
It is the responsibility of the Principal to communicate and provide a copy of this Living Will to their physician(s) and healthcare provider(s). In the event of the Principal's incapacity, it is the responsibility of the family, caregivers, or healthcare proxies/agents to provide the attending healthcare professionals with a copy of this Living Will to ensure the Principal’s healthcare preferences are honored.