Massachusetts Living Will Form
ANOTEABOUTTHISDOCUMENT
MassachusettsisoneofthreestatesthatdonotrecognizeLivingWills,sothisformwillnotbelegallyvalid.
However,aLivingWilllikethiscanstillbeinvaluableinhelpingtoguideyourHealthCareProxyorotherfamilymemberswhomayberesponsibleforyourcaredecisions.
WehaveprovidedthisformasanexamplebasedonLivingWillformsfromotherstates.Youmaymakechangestothisformoruseanyotherformtobetterexpressyourhealthcarewishes.
PART1:TREATMENTPREFERENCES
A.StatementofGoalsandValues
Optional:Formvalidi leftblank
Iwanttosaysomethingaboutmygoalsandvalues,andespeciallywhat’smostimportanttomeduringthelastpartofmylife:
B.Preference inCaseofTerminalCondition
Ifyouwanttostatewhatyourpreferenceis,initialoneonly Ifyoudonotwanttostateapreferencehere,crossthroughthewholesection.
Ifmydoctorscertifythatmydeathfromaterminalconditionisimminent,eveniflife‐
sustainingproceduresareused:
1. Keepmecomfortableandallownaturaldeathtooccur.Idonotwantanymedicalinterventionsusedtotrytoextendmylife.Idonotwanttoreceivenutritionandfluidsbytubeorothermedicalmeans.
>OR<
2. Keepmecomfortableandallownaturaldeathtooccur.Idonotwantmedicalinterventionsusedtotrytoextendmylife.IfIamunabletotakeenoughnourishmentbymouth,however,Iwanttoreceivenutritionandfluidsbytubeorothermedicalmeans.
>OR<
3. Trytoextendmylifeforaslongaspossible,usingallavailableinterventionsthatinreasonablemedicaljudgmentwouldpreventordelaymydeath.IfIamunabletotakeenoughnourishmentbymouth,Iwanttoreceivenutritionandfluidsbytubeorothermedicalmeans.
C.Preference inCaseofPersistentVegetativeState
Ifyouwanttostatewhatyourpreferenceis,initialoneonly Ifyoudonotwanttostateapreferencehere,crossthroughthewholesection.
IfmydoctorscertifythatIaminapersistentvegetativestate,thatis,ifIamnotconsciousandamnotawareofmyselformyenvironmentorabletointeractwithothers,andthereisnoreasonableexpectationthatIwilleverregainconsciousness:
1. Keepmecomfortableandallownaturaldeathtooccur.Idonotwantanymedicalinterventionsusedtotrytoextendmylife.Idonotwanttoreceivenutritionandfluidsbytubeorothermedicalmeans.
>OR<
2. Keepmecomfortableandallownaturaldeathtooccur.Idonotwantmedicalinterventionsusedtotrytoextendmylife.IfIamunabletotakeenoughnourishmentbymouth,however,Iwanttoreceivenutritionandfluidsbytubeorothermedicalmeans.
>OR<
3. Trytoextendmylifeforaslongaspossible,usingallavailableinterventionsthatinreasonablemedicaljudgmentwouldpreventordelaymydeath.IfIamunabletotakeenoughnourishmentbymouth,Iwanttoreceivenutritionandfluidsbytubeorothermedicalmeans
D.Preference inCaseofEnd‐StageCondition
Ifyouwanttostatewhatyourpreferenceis,initialoneonly Ifyoudonotwanttostatepreferencehere,crossthroughthewholesection.
IfmydoctorscertifythatIaminanend‐statecondition,thatis,anincurableconditionthatwillcontinueinitscourseuntildeathandthathasalreadyresultedinlossofcapacityandcompletephysicaldependency:
1. Keepmecomfortableandallownaturaldeathtooccur.Idonotwantanymedicalinterventionsusedtotrytoextendmylife.Idonotwanttoreceivenutritionandfluidsbytubeorothermedicalmeans.
>OR<
2. Keepmecomfortableandallownaturaldeathtooccur.Idonotwantmedicalinterventionsusedtotrytoextendmylife.IfIamunabletotakeenoughnourishmentbymouth,however,Iwanttoreceivenutritionandfluidsbytubeorothermedicalmeans.
>OR<
3. Trytoextendmylifeforaslongaspossible,usingallavailableinterventionsthatinreasonablemedicaljudgmentwouldpreventordelaymydeath.IfIamunabletotakeenoughnourishmentbymouth,Iwanttoreceivenutritionandfluidsbytubeorothermedicalmeans.
E.PainRelief
Nomatterwhatmycondition,givemethemedicineorothertreatmentIneedtorelievepain.
F.InCaseofPregnancy
Optional,forwomenofchildbearingyearsonly;formvalidifleftblank
IfIampregnant,mydecisionconcerninglife-‐sustainingproceduresshallbemodifiedasfollows:
G.EffectofStatedPreferences
Readbothofthesestatementscarefully.Then,initialoneonly.
1. IrealizeIcannotforeseeeverythingthatmighthappenafterIcannolongerdecideformyself.Mystatedpreferencesaremeanttoguidewhoeverismakingdecisionsonmybehalfandmyhealthcareproviders,butIauthorizethemtobeflexibleinapplyingthesestatementsiftheyfeelthatdoingsowouldbeinmybestinterest.
>OR
2. IrealizeIcannotforeseeeverythingthatmighthappenafterIcannolongerdecideformyself.Still,Iwantwhoeverismakingdecisionsonmybehalfandmyhealthcareproviderstofollowmystatedpreferencesexactlyaswritten,eveniftheythinkthatsomealternativeisbetter.
PART2:SIGNATUREANDWITNESSES
BysigningbelowastheDeclarant,IindicatethatIamemotionallyandmentallycompetenttomakethisadvancedirectiveandthatIunderstanditspurposeandeffect.IalsounderstandthatthisdocumentreplacesanysimilaradvancedirectiveImayhavecompletedbeforethisdate.
By: Date:
SignatureofDeclarantMonth/Day/Year
TheDeclarantsignedoracknowledgedsigningthisdocumentinmypresenceand,baseduponpersonalobservation,appearstobeemotionallyandmentallycompetenttomakethisadvancedirective.
Date:
SignatureofWitness1Month/Day/Year
PhoneNumber(s)
Date:
SignatureofWitness2Month/Day/Year
PhoneNumber(s)
Note:Anyoneselectedasahealthcareproxyshouldnotbeawitness.Also,atleastoneofthewitnessesshouldbesomeonewhowillnotknowinglyinheritanythingfromtheDeclarantorotherwiseknowinglygainafinancialbenefitfromtheDeclarant’sdeath.Moststatesdonotrequirethisdocumenttobenotarized.