Illinois Living Will Template
This Living Will is created pursuant to the Illinois “Natural Death Act” (755 ILCS 35/1 et seq.). It allows individuals to express their wishes regarding medical treatment in the event they become unable to communicate those wishes themselves.
Personal Information
- Name: ____________________________
- Date of Birth: ____________________
- Address: __________________________
- City: _____________________________
- State: ____________________________
- Zip Code: _________________________
Declaration
I, __________________________ (Name), being of sound mind, do hereby declare that this Living Will reflects my desires concerning the provision of medical care in the event I become incapacitated and unable to communicate.
Medical Treatment Preferences
If I am diagnosed with a terminal condition, or if I am in a persistent vegetative state, my wishes regarding medical treatment are as follows:
- I do not wish to receive life-sustaining treatment if it serves only to prolong the process of dying.
- I wish to receive pain relief even if it may hasten my death.
- I would like hydration and nutrition to be provided for as long as possible unless it is deemed futile or only prolongs suffering.
Healthcare Agent (Optional)
If I become unable to make my own medical decisions, I appoint the following person as my healthcare agent:
- Name: ____________________________
- Relationship: ______________________
- Address: __________________________
- Phone Number: _____________________
Signature
By signing below, I acknowledge that I understand the contents of this Living Will and that my wishes regarding medical treatment are to be followed:
Signature: ___________________________
Date: _______________________________
Witnesses
This Living Will must be witnessed by two adult individuals who are not related to me and who will not inherit anything from me:
- Witness 1: ______________________
- Witness 2: ______________________
Witness 1 Signature: ________________________
Date: _____________________________________
Witness 2 Signature: ________________________
Date: _____________________________________