This North Dakota Living Will is a legal document that outlines your specific wishes regarding medical treatment, especially in situations where you are unable to communicate these preferences due to a medical condition. By completing this Living Will, you can ensure that your healthcare providers and loved ones are clearly aware of your desires, thus relieving them from the burden of making difficult decisions on your behalf. This document adheres to the North Dakota Uniform Health Care Decisions Act (Chapter 23-06.5 of the North Dakota Century Code).
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Part 1: Basic Information
Full Legal Name: ___________________________________________________________
Date of Birth: ___________________________
Address: _________________________________________________________________
City: ______________________________ State: ND Zip Code: _____________
Phone Number: ____________________________
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Part 2: Health Care Directives
This section of your Living Will allows you to set forth your preferences in regards to receiving, withholding, or withdrawal of medical treatment in certain situations. Please initial next to the statements you agree with:
- ____ If I am in a terminal condition and unable to communicate, I do not want my life to be prolonged by artificial means, including mechanical ventilation, artificial nutrition, and hydration.
- ____ If I am in a persistent vegetative state or permanently unconscious with no hope of recovery, I do not want lifesaving treatments to be used.
- ____ I wish to receive maximum pain relief, even if it may hasten my death.
- ____ If I am unable to make my own health care decisions, I designate the following individual as my health care agent to make such decisions for me:
Agent's Full Name: _____________________________________________________
Relationship to Me: ____________________________________________________
Agent's Phone Number: __________________________________________________
- ____ In the absence of my primary agent, I designate the following individual as my alternate health care agent:
Alternate Agent's Full Name: ____________________________________________
Alternate Agent's Relationship to Me: ___________________________________
Alternate Agent's Phone Number: _________________________________________
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Part 3: Organ Donation
Upon my death, I wish to donate:
- ____ Any needed organs or tissues
- ____ Only the following organs or tissues: ____________________________
- ____ I do not wish to donate any organs or tissues.
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Part 4: Signature
I understand that this document revokes any prior Living Wills or similar documents. I affirm that I am of sound mind and that I fully understand the contents and implications of this Living Will.
Date: ___________________________
Signature: _______________________
Print Name: ______________________
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Part 5: Witness Statement
We, the undersigned, declare that the person signing this document:
- Is personally known to us or has been identified by proof;
- Appears to be of sound mind and not under duress, fraud, or undue influence;
- Has signed this document in our presence.
Witness 1: ___________________________________ Date: _________________
Print Name: __________________________________________________________
Witness 2: ___________________________________ Date: _________________
Print Name: __________________________________________________________
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Part 6: Notarization (Optional)
This document was acknowledged before me on (date) _______________ by (name of principal) ________________________.
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(Seal) Notary Public
My commission expires: _____________