Living Will Template for Rhode Island State

Rhode Island Living Will Template

This Living Will is created in accordance with the Rhode Island Rights of the Terminally Ill Act. It is a legal document that outlines your desires regarding medical treatment if you become unable to communicate your wishes due to illness or incapacity. Completing this document ensures that your healthcare preferences are known and considered by family members and healthcare providers.

Personal Information:

• Full Name: _______________________________
• Date of Birth: ___________________________
• Address: __________________________________
• City: _____________________________________
• State: Rhode Island
• Zip Code: ________________________________
• Phone Number: _____________________________

Directions Regarding Health Care:

I, _________________________ (your name), being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, and I declare that:

1. If I am in a terminal condition, I direct that life-sustaining treatments be withheld or withdrawn. Life-sustaining treatments include any medical procedure, artificial ventilation, renal dialysis, surgical procedure, or intervention that serves only to prolong the process of dying.
2. If I am in a state of permanent unconsciousness, and there is no reasonable expectation of my recovering data consciousness, I direct that all life-sustaining treatments be withheld or withdrawn.
3. I wish to receive all necessary measures for comfort care, pain relief, and symptom management, even if they hasten my death.

Appointment of Health Care Agent (Optional):

If you wish to appoint a Health Care Agent to ensure your wishes are carried out or to make decisions on your behalf if you become unable to make those decisions yourself, provide the information below:

• Health Care Agent's Full Name: _______________________________
• Relationship to You: ________________________________________
• Address: ____________________________________________________
• City: ________________________________________________________
• State: _______________________________________________________
• Zip Code: ____________________________________________________
• Phone Number: _______________________________________________

Signatures:

This document must be signed by two witnesses, neither of whom should be a spouse or a blood relative. It becomes effective only when you are unable to communicate your wishes regarding your medical treatment.

Your Signature: _____________________________ Date: _______________

Witness 1 Signature: ________________________ Date: _______________

Witness 2 Signature: ________________________ Date: _______________