Pennsylvania Living Will Form

The Pennsylvania living will is a legal document that must be completed by a person (Principal) who is interested in arranging their medical choices in advance in the event they face an end of life scenario. The wishes of the Principal would be legally protected with presentation of this document, if necessary. The Principal may name their health care agent to take over medical decision making processes when they are no longer able to decide their medical treatment on their own. This form must be completed while the Principal is of sound mind. The document must be witnessed OR acknowledged by a notary public.

Laws – 20§5441-47

How to Write

Step 1 – Download the form – Read the information in the first section addressing the Principal’s choices in the event of an end stage health condition – If the Principal would like to receive the listed treatments enter “I do want” on the line next to the selection as follows:

  • Heart-lung resuscitation (CPR)
  • Mechanical ventilator (breathing machine)
  • Dialysis (kidney machine)
  • Surgery
  • Chemotherapy
  • Radiation treatment
  • Antibiotics
  • AND
  • Initial one or both of the following:
  • Tube Feeding
  • No Tube Feeding

Step 2 – Health Care Agent’s Use of Instructions –

  • Initial only one of the options
  • If there will be exceptions with regard to the Agent’s powers, enter them into the lines provided
  • Read “Legal Protection”

Step 3 – Organ Donation –

  • Initial only one of the options in this section

Step 4 – Signatures of Witnesses OR Notarization (Optional) – Provide the following:

  • Date of witnesses signatures in dd/m/yy format
  • Witnesses must provide signatures for power of attorney and health care treatment instructions
  • OR
  • If the Principal prefers witness of a notary public, the Principal must sign before the notary
  • The notary will complete the section and acknowledge the document by affixing their official seal

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