Virginia Living Will
This Living Will is made in accordance with the laws of the Commonwealth of Virginia. It expresses my wishes regarding medical treatment in situations where I am unable to communicate my decisions.
My Name: ____________________________
Date of Birth: ____________________________
Address: ____________________________
City, State, Zip: ____________________________
If I become unable to make my own healthcare decisions and I have a terminal condition, I wish to direct my medical care as follows:
- I do not wish to receive life-prolonging treatments, including but not limited to:
- Mechanical ventilation
- Cardiopulmonary resuscitation (CPR)
- Artificial nutrition and hydration
- Alternatively, I wish to receive comfort care and pain relief.
Additional wishes or instructions:
____________________________________________
____________________________________________
My Agent: (If applicable) ____________________________
Agent's Phone Number: ____________________________
Agent's Address: ____________________________
This Living Will revokes any prior statements made by me regarding my healthcare preferences.
Signed this _____ day of _______________, 20____.
Signature: ____________________________
Printed Name: ____________________________
Witnesses:
Witness 1: ____________________________
Witness 2: ____________________________
This document should be kept in a safe place and copies provided to my healthcare agent and healthcare providers.