NC Living Will Form

Home
Up

Due to the Terri Schiavo debate,our office has received an overwhelming amount of requests for the NC Living Will Form. Unfortunately we are unable to supply the demand. I have included a pdf file so you may download a copy of this document.

Download NC Living Will Form

North Carolina Statutory Form, G.S. 90-321

NORTH CAROLINA COUNTY OF ___________________________________________

DECLARATION OF A DESIRE FOR A NATURAL DEATH

I, ___________________________________, being of sound mind, desire that, as specified below, my life not be prolonged by extraordinary means or by artificial nutrition or hydration, if my condition is determined to be terminal and incurable, or if I am diagnosed as being in a persistent vegetative state. I am aware and understand that this writing authorizes a physician to withhold or discontinue extraordinary means or artificial nutrition or hydration, in accordance with my specifications set forth below:

(Initial any of the following, as desired):

If my condition is determined to be terminal and incurable, I authorize the following:

________ (initials) My physician may withhold or discontinue extraordinary means only.

________ (initials) In addition to withholding or discontinuing extraordinary means if such means are necessary, my physician may withhold or discontinue either artificial nutrition or hydration, or both.

(Initial any of the following, as desired):

If my physician determines that I am in a persistent vegetative state, I authorize the following:

________ (initials) My physician may withhold or discontinue extraordinary means only.

This is _________ day of _____________________, __________.

Signature: ____________________________________________

I hereby state that the Declarant, ___________________________________, being of sound mind signed the above declaration in my presence and that I am not related to the Declarant by blood or marriage and that I do not know or have a reasonable expectation that I would be entitled to any portion of the estate of the Declarant under any existing will or codicil of the Declarant or as an heir under the Intestate Succession Act if the Declarant died on this date without a will. I also state that I am not the Declarant's attending physician or an employee of the Declarant's attending physician, or an employee of a health facility in which the Declarant is a patient or an employee of a nursing home or any group-care home where the Declarant resides. I further state that I do not now have any claim against the Declarant.

Witness Signature: ________________________________________

CERTIFICATE

I, ___________________________________, Clerk (Assistant Clerk) of Superior Court or Notary Public (circle one as appropriate) for _______________________________ County hereby certify that __________________________________, the Declarant, appeared before me and swore to me and to the witnesses in my presence that this instrument is his/her Declaration Of A Desire For A Natural Death, and that he/she had willingly and voluntarily made and executed it as his/her free act and deed for the purposes expressed in it.

I further certify that ___________________________________ and ___________________________________, witnesses appeared before me and swore that they witnessed ___________________________________, Declarant, sign the attached Declaration, believing him/her to be of sound mind; and also swore that at the time they witnessed the declaration (i) they were not related within the third degree to the Declarant or to the Declarant's spouse, and (ii) they did not know or have a reasonable expectation that they would be entitled to any portion of the estate of the Declarant upon the Declarant's death under any will of the Declarant or codicil thereto then existing or under the Intestate Succession Act as it provides at that time, and (iii) they were not a physician attending the Declarant or an employee of an attending physician or an employee of a health facility in which the Declarant was a patient or an employee of a nursing home or any group-care home which the Declarant resided, and (iv) they did not have a claim against the Declarant. I further certify that I am satisfied as to the genuineness and due execution of the declaration.

Dated this _____ day of ___________________, ___________.

_________________________________________________________

Clerk (Assistant Clerk) of Superior Court or Notary Public (circle one as appropriate) for the county of ______________________________.

If you would like a copy of this document send a self-addressed, stamped envelope to GHHA, 665 South Main St, Suite 204, Sparta, NC 28675.

Make It Legal

_____ You must be an adult (18 in most states) and mentally competent to execute a valid document. The document must be signed and dated in order to be effective.

_____ You should sign this document in the presence of 1) two witnesses who then sign the document in your presence and in each other's presence and 2) a notary who then notarizes the document.

_____ North Carolina requires that special provisions within the document be separately initialed or signed.

_____ The specific requirements for who can be a witness, whether the document must be notarized, and other execution formalities are printed on the document itself. MUST BE READ CAREFULLY AND COMPLIED WITH TO HELP ENSURE YOU HAVE A VALID DOCUMENT.

_____ You should initial on the bottom margin of each page of the document. This prevents the subsequent substitution of pages.

_____ An indication should be made on the document itself regarding who has received a copy, in case there is a need for later retrieval, modification, or revocation.

Copies

* Give a signed copy of the document to:

_____ Your health care provider(s), including your physician and any hospital where you are treated

_____ Appropriate family members, a close friend, or clergy

* You should retain the original or a copy of the document for your own records.

When to Consult a Lawyer

* The document may not be valid in other states of residence. A lawyer should be consulted if there is any uncertainty regarding which state's document to use.

* Before signing the document, you should be completely comfortable that you understand the nature and range of decisions that may be made on your behalf. You should discuss the range of medical decisions with a physician, another health care provider, social worker, pastor, or a lawyer -- someone who is knowledgeable about these issues and can answer questions.

Other Information

* While each state has its own restrictions on who may be a witness, in general, persons should not be used as a witness if they have been appointed as your Agent in the directive; are your relative by blood, marriage, or adoption; are or may become directly involved in providing health care to you; are an employee of your health care provider; or are less than 18 years of age.

* If you learn that you have a terminal condition after signing a health care directive, execute a new Directive. This will provide an opportunity to restate or change your wishes in light of your new health status.

Reasons to Update

* Change or set limits on the medical care that is provided.

* Respond to a changing medical technology.

* Respond to a change in health care laws.

* Respond to a change in health, including pregnancy.

* Designate a different person to make health care decisions for you.