New York Living Will Declaration Form

New York Living Will Declaration Form

Laws and Statutes to adhere to

Signatures must be witnessed by two witnesses (PBH 2981). Section 400.21(b) of the Code of Federal Regulations

How and what to put into writing for a New York Living will

Step 1: Download a copy of the New York Living Will

The New York Living Will may be downloaded as a PDF file by selecting "PDF" from the drop-down menu. Use the Adobe PDF link above to get the proper template. 

Step 2: Make it clear that you're in charge and define your duties as Principal

Take your time going through everything. This is an important step. When you're ready to put your medical care preferences in writing, look for a blank line between the words "I" and "Being Of Sound Mind..." and type the name of the principal. You can do this whenever you're ready. 

Step 3: Specify whether or not you want your family to know about your medical treatment.

In the case that you are chronically unconscious (or semi-conscious) or incoherent, you may activate or deactivate life-prolonging treatments by initialing the applicable phrases in the "Life-Sustaining Treatments" section. Consider all your alternatives carefully before making a decision. Starting with "(A) Choice Not To Prolong Life" in parenthesis indicates that you do not intend to be subjected to life-extending therapies because of your terminal illness or your loss of the ability to remain awake throughout the treatment process (or coherent).

The Principal has determined that no further treatment should be offered to a patient who is unable to communicate because of a deadly illness. There are no longer any open spots in any of the preceding brackets.

Begin by establishing a list of the treatments you are strongly opposed to. This job can be completed quickly and easily if you refer to the list at the end of option A. People in New York City will be administered cardiopulmonary resuscitation unless they complete a document stating that they "DO NOT WANT CARDIAC RESUSCITATION." To assist you to keep your ability to breathe intact, the New York Medical Staff may be summoned in rare instances. If you do not desire mechanical respiration, you should begin the second "...Mechanical Respiration" statement on this list.

It is recommended that those opposed to artificial hydration or nutrition begin with the third sentence on this list ("I Do Not Want Artificial Nutrition or Hydration") (i.e. using tubes or an IV).

You may revoke your permission to use antibiotics for your disease by signing the final statement description. – You ("I Do Not Want Antibiotics").

Make sure you get the medical attention you need to survive. "(B) Choice To Prolong Life" should be filled in if none of the following statements apply to you, even if your ability to remain awake or lucid is permanently damaged.

Step 4 - Dispense any pain management restrictions or limitations that may be necessary.

The presence of excruciating pain is a common symptom of a terminal or life-threatening disease. The medical staff at New York Hospitals and Medical Centers use a variety of pain medications and pain management techniques to help patients manage their pain. The section "Relief from Pain" may be used even if you are sleeping and unable to express your worries. Additionally, this area may be utilized to restrict, limit, or cancel your consent to pain relief. If you'd like, you may add more blank lines or an attachment providing the details of your pain management plan to this area. There is no obligation on your part to disclose any preferences.

Step 5: Give the New York Medical Staff your instructions.

If you have any further instructions for the New York Physician or Medical Staff taking care of you, please provide them in the "Other Wishes" box. In this part, you are free to discuss medical conditions, symptoms, and treatment alternatives, as well as your preferences and limitations. You should consult with your doctor, a qualified professional (such as a medical attorney), and/or any Health Care Agent before submitting your requests on this page. If you don't want to make any further comments, just leave these lines blank.

Step 6: Provide information on how to donate organs if wanted.

This issuing might be used to keep track of posthumous anatomical contributions. The part is listed under "Opportunity Organ Donation." After "Upon My Death," enter "(A) I Do Not..." if you do not want your organs, tissues, or body parts to be donated.

After death, if you want to donate an organ, tissue, or other parts of your body, make sure you sign and date the line that reads "(B) I Give..." Organs and body components may be entered straight into the system in this area if that is all you wish to do. Enter your post-death anatomical donation information in the "(C) I Give The Following..." section of this report.

Step 7: Describe the limitations of anatomical gifts.

To impose limits on the usage of anatomical gifts, go to the next category (beginning with "Transplant" and ending with "Education"). Initialing any of the items on this list signifies your strong objection to the practice of donating human organs for research. The first item on this list should be initialed if you do not desire to donate any organs or body parts for a "Transplant," for example. "Therapy" should be the primary choice for those who don't wish to be remembered through an organ or other anatomical donation. The third item on the list should be initialed if you do not want your organs, tissues, or other body components given for "Research."

Start the last item with "Education" if you wish to restrict the admission of anatomical contributions to medical institutions or colleges.

8. Ensure your instructions are followed in the presence of two witnesses.

For this legal document to be approved, you must confirm that the information included in it is correct. Consequently, two witnesses who are not blood relatives of the signatory and who have no financial interest in your estate are required to sign the document. Before signing "Part III. Execution," please read and understand all you have supplied thus far. Respond to this line with the current date and time once you've logged out.

For clarity's sake, provide your name on the following line. Finally, fill out the "Address" field with your information. Include a physical location and phone number in an address (e.g. a residential building number; a street and unit number; a city in New York County; a zip code).

Step 9: Hand your work along to the witnesses for verification.

After completing the "Execution" section of the document in the presence of two witnesses, distribute this paperwork to the parties participating in the execution process. If you want your signature to be verified, you'll need Witness 1 to read and sign the statement that starts "I Declare...". Witness 1 must sign the "Signed" line and then put the "Date" of his or her signature next to the one provided during the "Witness 1" section.

After submitting his or her signature, Witness 1 must print their name on the "Print Name" section underneath the signature box.

When it comes time to finish off the witness testimony, a copy of Witness 1's "Address" might be sent to the last "Witness 1" section participant. A second witness is required to vouch for the correctness of the procedure. The "Signed" line on the "Witness 2" heading must include the signature of Witness 2, and the current "Date" must be noted as the date on which his or her signature was obtained. As the last step, enter Witness 2's printed name in the "Print Name" field beneath the supplied signature. In cases when the second witness has a home address, the "Address" lines must be filled in.