Minnesota Living Will Template
This Minnesota Living Will is a legal document that outlines your healthcare preferences in the event you are unable to communicate these decisions yourself. It is designed in accordance with the Minnesota Health Care Directive Act, allowing you to state your wishes regarding medical treatment and end-of-life care.
Please complete the following information:
Full Name: _______________________________
Date of Birth: _______________________________
Social Security Number: ________________________
Address: _____________________________________
City: _____________________ State: MN Zip Code: _________
Health Care Preferences:
This section allows you to specify your preferences when you are no longer able to make decisions concerning your health care. Please indicate your wishes clearly.
- Life-Sustaining Treatment:
In situations where I am unable to make decisions for myself and am in a condition that is deemed terminal or permanently unconscious, I wish for the following approach to my care (choose one):
- To receive all available treatments that might extend my life, including but not limited to mechanical ventilation, resuscitation, and artificial hydration and nutrition.
- To decline life-sustaining treatments that would only serve to prolong the process of dying or to maintain me in a condition of permanent unconsciousness. I wish to receive only treatments that are necessary for my comfort and pain relief.
- Artificial Nutrition and Hydration:
Regarding the provision of artificial nutrition (feeding through a tube) and hydration (fluids through a tube), I wish (choose one):
- To receive artificial nutrition and hydration regardless of my medical condition.
- To refuse artificial nutrition and hydration when it is clear that the burdens outweigh the expected benefits, or in the event that I am in a permanent unconscious state.
- Other Instructions:
Please provide any additional instructions or specific treatments you desire or do not desire:
Designation of Health Care Agent:
This section allows you to appoint someone as your health care agent. This person will have the authority to make health care decisions on your behalf, according to your wishes and interests, if you are unable to do so yourself.
Agent's Full Name: _______________________________
Relationship to You: _______________________________
Agent's Address: ___________________________________
City: _____________________ State: _____ Zip Code: _________
Agent's Telephone Number: ___________________________
Alternate Agent: (Optional)
In the event your primary agent is unable or unwilling to serve, you may designate an alternate agent.
Alternate Agent's Full Name: _________________________
Relationship to You: _________________________________
Alternate Agent's Address: ___________________________
City: _____________________ State: _____ Zip Code: _________
Alternate Agent's Telephone Number: _____________________
Signatures:
This document does not become effective unless you are unable to communicate your health care decisions. Two witnesses or a notary public must sign this document, verifying your signature. Witnesses must not be your health care provider or an employee of your health care provider, nor should they be the designated health care agent or alternate agent.
___________________________
Your Signature
Date: _________________
Witness 1: _____________________________
Signature: _______________________________
Date: _________________
Witness 2: _____________________________
Signature: _______________________________
Date: _________________
Or
Notary Public: __________________________
Signature: _______________________________
Date: ________________