Free Living Will Document for the State of Kansas

This Living Will is an important legal document that outlines your healthcare wishes, specifically your desires regarding medical treatment and life-sustaining measures, in the event you are unable to communicate them yourself. It is created in accordance with the Kansas Living Will Act.

Personal Information

Full Name:

Date of Birth:

Address:

City: State: KS Zip Code:

Healthcare Directives

In accordance with the Kansas Living Will Act, I, _______________________ [insert your name], being of sound mind, voluntarily direct the following:

1. Any life-sustaining treatment should be withheld or withdrawn if I:
   • am in a permanent vegetative state;
   • am in an irreversible coma;
   • have a terminal condition where the application of life-sustaining procedures would only artificially prolong the process of dying.
2. I specifically:
   • Desire the administration of nutrition and hydration artificially;
   • Do not desire the administration of nutrition and hydration artificially;
   • Wish these decisions regarding nutrition and hydration to be made by my designated healthcare agent.
3. I designate the following individual as my healthcare agent to make decisions regarding my medical care, including decisions about life-sustaining treatments, if I am unable to make these decisions myself:

   Name:

   Relationship:

   Phone Number:

4. Should my primary healthcare agent be unavailable, unwilling, or unable to act on my behalf, I designate the following alternate agent:

   Name:

   Relationship:

   Phone Number:

By executing this Living Will, I affirm that my healthcare agent's authority is subject to any limitations I have outlined herein.

Signature: _______________________________________ Date:

This document should be provided to the healthcare agent, alternate agent (if any), and my primary healthcare provider.

Witness Declaration

I declare that the principal appears to be of sound mind and free from duress at the time of signing this document, and that I am not the person appointed as healthcare agent by this document.

Witness 1 Signature: _______________________________________ Date:

Witness 2 Signature: _______________________________________ Date: