Ohio Living Will Declaration
This Ohio Living Will Declaration is created in accordance with the Ohio Revised Code, Chapter 2133. This document allows you to express your wishes regarding medical treatment in the event that you become unable to make those decisions yourself.
Please fill in the following information to personalize your Living Will:
- Name: ___________________________
- Date of Birth: _____________________
- Address: __________________________
- City, State, Zip Code: _____________
- Phone Number: ____________________
Statement of Wishes:
I, _____________________ (name), being of sound mind, wish to make known my desires concerning my medical care in the event that I become unable to communicate my wishes. This includes situations where I may be terminally ill or in a persistent vegetative state.
I request that the following treatments, procedures, or interventions be considered or withheld in accordance with my wishes:
- Life-Sustaining Treatment: I ______________ (choose to / choose not to) receive life-sustaining treatments that may prolong my life.
- Artificial Nutrition and Hydration: I ______________ (choose to / choose not to) receive artificial nutrition and hydration if I am unable to eat or drink.
- Pain Relief: I wish to receive medication or other treatments to alleviate pain, even if it may hasten my death.
Designated Health Care Agent:
If I am unable to communicate, I designate the following person to make health care decisions on my behalf:
- Name of Health Care Agent: ________________________
- Relationship: ______________________
- Address: __________________________
- Phone Number: ____________________
I empower my health care agent to act in full accordance with my wishes as stated in this document. If my agent is unavailable, I authorize the following alternate:
- Name of Alternate Agent: ______________________
- Relationship: ______________________
Signature:
By signing below, I confirm that I understand the purpose and effect of this Living Will Declaration:
Signed: ___________________________
Date: ___________________________
Witnesses’ Signatures:
Two witnesses must sign this document, but they cannot be related to you by blood or marriage, or entitled to any part of your estate.
- Witness 1 Name: _______________________
- Witness 1 Signature: ____________________
- Date: __________________________
- Witness 2 Name: _______________________
- Witness 2 Signature: ____________________
- Date: __________________________
This Ohio Living Will Declaration expresses my wishes regarding medical treatment and constitutes my legal direction regarding health care decisions.