Fillable Living Will Form for Utah State

Utah Living Will Declaration

This Living Will Declaration is designed to express the wishes of the person signing the document (referred to as the "declarant") regarding their medical treatment in situations where they are unable to communicate their desires. This document is created in accordance with the Utah Advance Health Care Directive Act.

Declarant Information

• Full Name: ________________
• Date of Birth: ________________
• Address: ________________
• City: ________________, State: Utah, Zip: ________________
• Phone Number: ________________

Declaration

I, ________________ (the declarant), 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:

1. If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur unless life-sustaining procedures are utilized and that the application of life-sustaining procedures would only serve to prolong artificially the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally.
2. In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this declaration be honored by my family, physicians, and other health care providers as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences of such refusal.
3. If I am in a persistent vegetative state or if I am unconscious and it is unlikely that I will regain consciousness, I request that I not be kept alive through life-support systems, artificially provided nutrition (including feeding tubes), or hydration.
4. I give the following person(s) full power to make decisions for me regarding withholding or withdrawal of treatment when I am unable to do so:

   Name: ________________

   Relationship: ________________

   Phone Number: ________________

5. If the person named above is unable, unwilling, or unavailable to act on my behalf, I designate the following alternate:

   Name: ________________

   Relationship: ________________

   Phone Number: ________________

This declaration does not affect any necessary measures that may be taken to provide comfort care. For the purposes of this document, "comfort care" means treatment that is performed in an attempt to alleviate pain without artificially prolonging life.

Signatures

This declaration must be signed by the declarant, or another individual at the declarant's direction, in the presence of two witnesses or a notary public. The witnesses must not be related to the declarant by blood, marriage, or adoption, nor entitled to any portion of the estate of the declarant under any will or by operation of law.

Declarant's Signature: ________________ Date: ________________

Witness 1 Signature: ________________ Date: ________________

Printed Name: ________________

Witness 2 Signature: ________________ Date: ________________

Printed Name: ________________

OR

Notary Public Signature: ________________ Date: ________________

My commission expires: ________________

This Utah Living Will Declaration is made voluntarily by the declarant as an expression of their right to make decisions regarding their medical treatment.