Rhode Island Living Will Template
This document serves as a Living Will, crafted in accordance with the Rhode Island Rights of the Terminally Ill Act, specifically tailored for residents of Rhode Island to outline their wishes regarding medical treatment in scenarios where they are unable to communicate their desires themselves.
Personal Information
Full Name: ___________________________________________________________
Date of Birth: ________________________________________________________
Address: ______________________________________________________________
City: _________________________ State: Rhode Island Zip: _________
Health Care Directives
In the event that I, __________________________________ [insert name], am unable to make my own health care decisions due to incapacity or mental disability, I provide the following directives for my care. I trust this document will communicate my wishes clearly to family, health care agents, and medical personnel.
Life-Sustaining Treatment
I desire that life-sustaining treatment be:
- Provided in all circumstances.
- Limited to the circumstances described below.
- Withheld if the situation is deemed terminal and recovery is not expected.
Specific Instructions: _____________________________________________________________
________________________________________________________________________________
Artificial Nutrition and Hydration
Unless the situation appears as described within my specific instructions, artificial nutrition and hydration:
- Shall be provided.
- Shall be withheld.
Specific Instructions: _____________________________________________________________
________________________________________________________________________________
Other Instructions
You may specify any other instructions or health care directives you want to be followed below:
________________________________________________________________________________
________________________________________________________________________________
Primary Health Care Agent
In situations where I am unable to make my own health care decisions, I designate the following individual as my primary health care agent:
Name: _____________________________________
Relationship: ______________________________
Phone Number: ______________________________
Alternate Phone Number: ____________________
Secondary Health Care Agent (Optional)
Should my primary health care agent be unavailable, I designate the following individual as my secondary health care agent:
Name: _____________________________________
Relationship: ______________________________
Phone Number: ______________________________
Alternate Phone Number: ____________________
Signatures
This document represents my health care wishes and I affirm that I understand its contents. By signing below, I validate the directives specified in this Living Will.
Signature: ____________________________________ Date: ________________
Printed Name: ___________________________________________________________
Witness Signature: _____________________________ Date: _____________
Printed Name: ___________________________________________________________
Witness Statement: I declare that the person signing this document is personally known to me and appears to be of sound mind and under no duress, fraud, or undue influence. I am not the person appointed as the health care agent in this document.