Translation into English of Living Will - EXAMPLE

Advance Directive for Mr./Mrs. ……………………………………………………. Date: ………………………
To: …… Doctors, nurses, the hospital, or any related persons………………………………………

In the event I am admitted to a hospital for medical treatment and I am unable to speak, write, or perform any functions independently, I direct that I do not want to be kept alive by life-support systems in order to extend my life. I wish to die peacefully and with my dignity intact. I do not want and do not permit anyone to sustain my life by providing me water, food, or anything else by tubes inserted into my nostrils, mouth, or any part of my body (I allow use of a urinary catheter). I do not permit and do not want surgery or use of electronic equipment if my heart stops beating. Pain-relieving drugs and sleeping pills should be used to stop the pain only. 

The exceptions to the above comprise the following:

Injury to the brain, discovered during an x-ray, scan, or use of other medical equipment. The brain injury in this instance is minor and can be treated by surgery and the possibility of returning to normal is 90%. This exception is on condition that the surgery is done within 36 hours after I am admitted to a hospital.

I have contemplated this matter in detail and have consulted with …………………………………………………., lawyer at ……………………………………………………………,
address ……………………………………………………………………………………………………………………,
telephone number …………………………………………………, fax……………………………………………,
home phone number …………………………………………………

I have been acquainted with this person for many years and appoint ………………………. with full authority to decide on any questions related to my medical treatment that may arise.

I release all person from any responsibility or legal proceedings from following my orders or the order of my representative. On the other hand, any persons not following my orders above cannot subsequently require payment for medical treatment from me or the administrator of my estate.

Signed ………………………………….. (Declarant / Principal)

………………………………………….. (Witness)

………………………………………….. (Witness)

Signed ………………………………….. (Representative)

Disclaimer While this site does provide information on law-related topics, it does not provide legal advice. Moreover, due to the rapidly changing nature of the law and our reliance on information provided by outside sources, we make no warranty or guarantee concerning the accuracy or reliability of the content at this site or at other sites to which we link. Before taking any legal action, persons are advised to seek the advice of an attorney qualified in the area of law concerned