Suggested form of a Living Will, Florida Statutes Section 765.303
A living will may, BUT NEED NOT, be in the following form:
Declaration made this day of 2___, I _____________________________________willfully and
voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth
below, and I do hereby declare that, if at any time I am incapacitated and
(initial) I have a terminal condition.
(initial) I have an end stage condition.
or ______ (initial) I am in a persistent vegetative state,
and if my attending or treating physician and another consulting physician have determined that there is no
reasonable medical probability of my recovery from such condition, I direct that life-prolonging procedures be
withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process
of dying, and that I be permitted to die naturally with only the administration of medication or the performance of
any medical procedure deemed necessary to provide me with comfort care or to alleviate pain.
It is my intention that this declaration be honored by my family and physician as the final expression of my legal
right to refuse medical or surgical treatment and to accept the consequences for such refusal.
In the event that I have been determined to be unable to provide express and informed consent regarding the
withholding, withdrawal, or continuation of life-prolonging procedures, I wish to designate, as my surrogate to carry
out the provisions of this declaration:
I understand the full import of this declaration, and I am emotionally and mentally competent to make this
Additional Instructions (optional):