IllinoisLivingWillAct
(IllinoisCompiledStatutes,755ILCS35/1etseq.
DECLARATION
Thisdeclarationismadethis dayof (month,year).
I, beingofsoundmind,willfullyandvoluntarilymakeknownmydesiresthatmymomentofdeathshallnotbeartificallypostponed.
IfatanytimeIshouldhaveanincurableandirreversibleinjury,disease,orillnessjudgedtobeaterminalconditionbymyattendingphysicianwhohaspersonallyexaminedmeandhasdeterminedthatmydeathisimminentexceptfordeathdelayingprocedures,Idirectthatsuchprocedureswhichwouldonlyprolongthedyingprocessbewithheldorwithdrawn,andthatIbepermittedtodienaturallywithonlytheadministrationofmedication,sustenance,ortheperformanceofanymedicalproceduredeemednecessarybymyattendingphysiciantoprovidemewithcomfortcare.
Intheabsenceofmyabilitytogivedirectionsregardingtheuseofsuchdeathdelayingprocedures,itismyintentionthatthisdeclarationshallbehonoredbymyfamilyandphysicianasthefinalexpressionofmylegalrighttorefusemedicalorsurgicaltreatmentandaccepttheconsequencesfromsuchrefusal.
Signed
City,CountyandStateResidence
ThedeclarantispersonallyknowntomeandIbelievehimorhertobeofsoundmind.Isawthedeclarantsignthedeclarationinmypresence(orthedeclarantacknowledgedinmypresencethatheorshehadsignedthedeclaration)andIsignedthedeclarationasawitnessinthepresenceofthedeclarant.Ididnotsignthedeclarant’ssignatureabovefororatthedirectionofthedeclarant.Atthedateofthisinstrument,Iamnotentitledtoanyportionoftheestateofthedeclarantaccordingtothelawsofintestatesuccessionor,tothebestofmyknowl-edgeandbelief,underanywillofdeclarantorotherinstrumenttakingeffectatdeclarant’sdeath,ordirectlyfinanciallyresponsiblefordeclarant’smedicalcare.
Witness Witness
Forcopies,contacttheIllinoisDepartmentonAging
OneNaturalResourcesWay,#100,Springfield,IL62702-1271
SeniorHelpLineat
1-800-252-8966,1-888-206-1327(TTY)
TheIllinoisDepartmentonAgingdoesnotdiscriminateinadmissiontoprogramsortreatmentofemploymentinprogramsoractivitiesincompliancewithappropriateStateandFederalStatutes.Ifyoufeelyouhavebeendiscriminatedagainst,youhavearighttofileacomplaintwiththeIllinoisDepartmentonAging.Forinformation,calltheSeniorHelpLineat1-800-252-8966,1-888-206-1327(TTY).
PrintedbyAuthorityStateofIllinois,DepartmentonAgingIL-402-0764(Rev.6/11,16M)
What isaLivingWill?ALivingWillisadocumentinwhichapersoncandeclarehisorherdesiretohavedeath-delayingprocedureswithheldorwithdrawnintheeventheorshehasbeendiagnosedwithaterminalconditionbyaphysician.(SpecificdefinitionsareprovidedfortheselegaltermsintheIllinoisLivingWillAct).
What arethe advantagesof aLivingWill?ALivingWillassuresthatyourrightswillberespectedifyouarenotabletoactivelyparticipateindeath-delayingdecisionsrelatingtoyourownhealthcareduetoaphysicalormentalcondition.Additionally,aLivingWillsavesyourfamilyfromtheburdenofhavingtomakehealthcaredecisionsaboutconsentingtoorrefusingdeath-delayingprocedureswithoutknowingyourwishes.
Whomayexecute aLivingWill? Anypersonage18orolderwhoisaresidentofIllinoismayexecuteaLivingWillatanytime.TheLivingWilldocument(seereverseside)mustbesignedbyyouandtwo(2)independent witnesses.
Must anattorneyprepare the LivingWilldocumentfor you? AlthoughIllinoislawdoesnotrequirethatanattorneyprepareaLivingWilldocument,youmaywanttoconsultwithanattorneyforadditionalguidanceinprotectingyourinterestsusingadvancedirectives.
When shouldyou execute aLivingWill? ThebesttimeforyoutoexecuteaLivingWillisrightnow,longbeforeyouanticipateanythinghappeningtoyou.Thiswillensurethattheattendingphysicianandyourfamilyknowyourwishesifyouareeverinasituationwheredeath-delayingproceduresbecomenecessary.
When does aLivingWilltake effect? UnderIllinoislaw,aproperlysignedandwitnessedLivingWilltakeseffectonceapersonhasbeendiagnosedwithaterminalconditionandhisorherattendingphysicianverifiessuchinformationinwritingasapartofthemedicalrecord.
IftheattendingphysicianisunwillingtocomplywiththeinstructionsstatedinaLivingWilldocument,thenthephysicianmustnotifyhisorherpatientofthatfact.Ifthepatientisunabletoinitiateatransferofhisorhercaretoanotherphysician,thenthephysicianisrequiredbylawtonotify:(1)anypersonauthorizedbythepatienttomakesucharrangements,(2)thepatient’sguardian,or(3)anymemberofthepatient’sfamily.
HOWEVER,aLivingWillshallnotbegiveneffectsolongasanagentisavailablewhoisauthorizedtodealwithdeath-delaying decisionsonyourbehalfunderaDurablePowerofAttorneyforHealthCare.
How can aLivingWillbe revoked?YoumayrevokeyourLivingWillby(1)burning, tearing, orotherwisedestroyingordefacingthedocument,(2)signingawrittenrevocation,or(3)makinganoralrevocationinthepresenceofawitness18yearsofageorolderwhothenputstherevocationinwritingforyou.
Will your LivingWill berecognizedin anotherstate? Theanswerdependsonthelawsofeachstate. AlthoughmoststateswillrecognizeaLivingWill,somerequireadocumenttobebothwitnessedandnotarizedtobevalid.AfteryouexecuteaLivingWill,youmaywanttosignthisdocumentinthepresenceofyourwitnessesandanotarypublictoavoidanypossibleproblems.
HOWEVER,aLivingWilldocumentwhichhasbeenexecutedincompliancewiththelawofanotherstatewillberecognizedinIllinois.
Other thingsto consider:
(1)YoushouldtalktoyourphysicianaboutyourLivingWilltobesurethatheorshewillcomplywithyourinstructions aboutwithholding orwithdrawing death-delaying procedures.
(2)YoushouldgivetheoriginalLivingWilldocumentuponitscompletion(signed,witnessed,and
notarized)toyourphysician,andprovidecopiestoyourhealthcarefacility,hospital,lawyer,
agent underaDurablePowerofAttorneyforHealthCare,family,orotherindividualswhomyoucanrelyontoactaccordingtoyourinterestsandvalues.
(3)YoumaywanttomakeanoteaboutyourLivingWillonthereversesideofyourdriver’slicenseoradd anotificationcardtoyourwallet.