Illinois Living Will
This Living Will is created in accordance with Illinois state law. It expresses your wishes regarding medical treatment in the event you are unable to communicate them yourself.
Patient Information
- Name: ________________________________
- Date of Birth: ________________________
- Address: ______________________________
Declaration
I, ___________________________, being of sound mind, make this declaration to express my wishes regarding medical treatment in the event I become terminally ill or permanently unconscious:
- If I have a terminal condition, I do NOT want life-sustaining treatment that would merely prolong the dying process.
- In the case of a permanently unconscious state, I wish to forgo life-sustaining treatment.
- I desire comfort care and relief from pain at all times.
Revocation of Prior Directives
This Living Will revokes any prior directives made by me that relate to the same subject matter.
Signature
Signed this _____ day of __________, 20___.
______________________________
Signature of Declarant
Witnesses
This Living Will must be signed by two adult witnesses who are not related to the declarant, do not stand to inherit from the declarant, and are present when the declarant signs:
- Name: ____________________________ Signature: ________________________
- Name: ____________________________ Signature: ________________________
This Living Will is intended to ensure your preferences regarding medical treatment are honored. Keep this document in a safe place and provide copies to your healthcare providers and loved ones.