Wyoming Living Will Template
This Living Will is designed to reflect the desires of the undersigned, pertaining to health care decisions in the event of incapacitation, in accordance with the Wyoming Health Care Decisions Act.
Part I: Information of the Principal
Full Name: _______________________________________________
Date of Birth: ___________________________________________
Address: _________________________________________________
City: ______________________ State: WY Zip: _____________
Part II: Health Care Directives
In the event that I am unable to communicate my preferences directly, due to any form or condition of incapacitation, I wish my health care providers to follow the instructions as detailed below:
- Preference regarding life-sustaining treatment
In situations where my recovery is not expected, and I am unable to communicate my wishes:
_ I desire all available life-sustaining treatments, including artificially provided nutrition and hydration.
_ I do not desire life-sustaining treatment, except as necessary to provide comfort care.
- Preference in case of a terminal condition
If I am diagnosed with a condition that is considered terminal and incurable:
_ I wish to receive all treatments that may extend my life, including nutrition and hydration, artificially provided.
_ I do not desire any treatments that would serve only to prolong the process of dying.
- Preference in case of permanent unconsciousness
If I become permanently unconscious, with no reasonable expectation of recovery:
_ I wish for all available treatments to be provided, including artificially provided nutrition and hydration.
_ I wish to refrain from receiving any life-sustaining treatments, other than comfort care.
- Other specific instructions
Here, you may describe other preferences you have regarding your health care, including desires for pain management, hospitalization, and other treatments. Use additional sheets if necessary.
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Part III: Signature
I affirm that these health care instructions reflect my wishes:
Signature: _______________________________ Date: ________________
Part IV: Witnesses
This document must be signed in the presence of two qualified witnesses, who must also provide their signatures:
Witness 1:
Name: ___________________________________
Signature: _______________________________ Date: ________________
Witness 2:
Name: ___________________________________
Signature: _______________________________ Date: ________________
Note: This document does not authorize the withholding of hydration and nutrition unless explicitly stated.