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North Carolina Living Will Template

This Living Will is made in accordance with North Carolina General Statute § 90-321. It is intended to express your wishes regarding medical treatment in the event that you become unable to communicate your preferences.

Instructions: Complete the blanks below with your personal information and preferences.

Personal Information:

  • Name: _______________________________
  • Date of Birth: _______________________
  • Address: _____________________________
  • City, State, Zip: _____________________

Declaration:

I, _______________________________, being of sound mind, wish to declare my wishes regarding medical treatment in the event that I am diagnosed with a terminal condition, irreversible condition, or become permanently unconscious.

Preferences:

  • In the event of a terminal condition, I wish to receive:
    1. Life-sustaining treatment: Yes / No
    2. Palliative care only: Yes / No
  • If I am in a state of permanent unconsciousness, I wish to receive:
    1. Life-sustaining treatment: Yes / No
    2. Palliative care only: Yes / No

Signature:

By signing below, I affirm that I am of sound mind and making this declaration voluntarily.

Signed: ___________________________________

Date: ___________________________________

Witness Information:

  • Witness 1 Name: ________________________
  • Witness 1 Signature: ___________________
  • Witness 2 Name: ________________________
  • Witness 2 Signature: ___________________

This Living Will shall be effective upon my incapacity as determined by my physician. It is my intention that this document shall be honored by my family and healthcare providers.

⇓ Living Will PDF

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Similar forms

  • Advance Directive: An advance directive is a legal document that outlines a person's preferences for medical treatment in case they become unable to communicate. Like a living will, it provides guidance to healthcare providers regarding the individual's wishes for end-of-life care.
  • Durable Power of Attorney for Healthcare: This document allows an individual to appoint someone else to make healthcare decisions on their behalf if they are unable to do so. While a living will specifies medical preferences, a durable power of attorney designates a trusted person to interpret and act on those preferences.
  • Do Not Resuscitate (DNR) Order: A DNR order is a medical order that prevents healthcare providers from performing cardiopulmonary resuscitation (CPR) if a person's heart stops. Similar to a living will, it communicates specific wishes regarding life-sustaining treatment.
  • Mobile Home Bill of Sale: The Connecticut Mobile Home Bill of Sale form is crucial for documenting the transfer of ownership of a mobile home, providing security for both buyer and seller, and can be accessed through Auto Bill of Sale Forms.
  • Healthcare Proxy: A healthcare proxy is a document that appoints an individual to make healthcare decisions on behalf of another person when they cannot do so. Like a living will, it ensures that the individual's healthcare preferences are honored, but it relies on the appointed proxy to make those decisions.