Utah Living Will Template
This Utah Living Will Template is designed to be compliant with the requirements specified in the Utah Advance Health Care Directive Act. By completing this document, individuals can outline their preferences for medical treatment should they become incapacitated and unable to communicate their wishes. Please complete all blanks with the appropriate information.
Personal Information
Full Legal Name: ________________________________________________________
Date of Birth: ___________________________________________________________
Address: __________________________________________________________________
City: _____________________ State: UT Zip Code: _________________
Phone Number: ____________________________________________________________
Health Care Directive
I, the undersigned, being of sound mind, hereby direct that my health care providers and others involved in my care provide, withhold, or withdraw treatment in accordance with the choices I have marked below:
- Life-Prolonging Medical Procedures
_____ I do not want my life to be prolonged by medical treatment, artificial nutrition and hydration, or life support if my condition is terminal and cannot be cured or improved, and the burdens of treatment outweigh the benefits.
- Artificial Nutrition and Hydration
_____ I want to receive, or _____ I do not want to receive artificial nutrition and hydration if the only purpose of this treatment is to prolong my dying process.
- Pain Relief
_____ I want to receive treatment to relieve pain and other symptoms at any time, even if it hastens my death.
These directives are in accordance with Utah State law and reflect my specific wishes regarding my health care. I understand that I may revoke these directives at any time.
Signature
Date: __________________________________
Signature of Principal: _______________________________________________
Print Name: ____________________________________________________________
Witness Statement
I declare that the person signing this document is personally known to me and appears to be of sound mind and under no duress, fraud, or undue influence. I am not the person’s attending physician, an employee of the attending physician, or a health care facility in which the person is a patient. I am not related to the person by blood, marriage, or adoption, nor would I be entitled to any part of the person’s estate upon death under a will or by operation of law.
Date: __________________________________
Signature of Witness #1: _____________________________________________
Print Name: __________________________________________________________
Signature of Witness #2: _____________________________________________
Print Name: __________________________________________________________