Montana Living Will Template
This Montana Living Will is a legal document that outlines your wishes regarding medical treatment in the event that you are unable to communicate them yourself. It is made pursuant to the Montana Rights of the Terminally Ill Act. By completing this document, you can ensure that your health care preferences are respected and followed.
Instructions: Please complete the following information accurately. If you are unsure about any section, seek legal advice.
Personal Information
Full Name: ___________________________
Address: ___________________________
________________________________________
Date of Birth: ____________
Social Security Number: ____________
Living Will Statement
I, _________________________, being of sound mind, hereby make this declaration to guide my family and health care providers about my wishes for medical treatment if I become unable to communicate my desires.
Health Care Directives
My directives for health care when I am terminally ill, in a coma, or in a persistent vegetative state and unable to communicate my wishes directly are as follows:
- I wish to receive all treatments that could potentially cure my condition or extend my life for as long as possible.
- I wish to receive only treatments that would ease my pain or discomfort, even if such treatments do not extend my life.
- I do not wish to receive treatments that would extend my life artificially, such as mechanical ventilation, tube feeding, or other life-sustaining measures.
Please indicate your choice by circling the appropriate number above and initialing: _____________
Additional Instructions
If there are any additional specific treatments you do or do not wish to receive, list them here:
_________________________________________________________________
_________________________________________________________________
Designation of Health Care Agent
If I am unable to make health care decisions for myself, I hereby designate the following individual as my Health Care Agent:
Name: ___________________________
Relationship: ____________________
Phone Number: ____________________
Alternate Phone Number: ____________________
This person will have the authority to make all health care decisions for me, including decisions about refusing or withdrawing life-sustaining treatment, consistent with my wishes as stated in this document.
Signature
I understand that this document will only be used if I am unable to communicate my health care preferences myself. I affirm that I am completing this document of my own free will.
Date: ____________
Signature: ___________________________
This Living Will must be signed in the presence of two witnesses, who also need to sign the document.
Witnesses
Witness 1 Name: ___________________________
Witness 2 Name: ___________________________
Witness 1 Signature: ___________________________ Date: ____________
Witness 2 Signature: ___________________________ Date: ____________