Instructions for Completing Your
New York Living Will
A Living Will only becomes effective if you are determined to have a terminal illness or are at the
end-of-life and when you are no longer able to communicate your wishes. In New York State, the
Living Will was authorized by the courts (not by legislation) so there are no requirements guiding
its use. But, a Living Will can serve an important role to provide clear evidence of your wishes.
You can add personal instructions in Item 3 on the form if there are specific treatments that you
wish to refuse but are not listed on the document.
You can also add a statement referring to your health care agent such as, “Any questions about
how to apply my Living Will are to be decided by my health care agent.”
Item 1: Print your name
Item 2: Cross out any of the statements that do not reflect your wishes
Item 3: Write in any personal instructions
Item 4: Date and sign the document and include your address
Item 5: Two witnesses must sign the document and print their addresses.
Note: This form does not need to be notarized.
“Completing Your New York Living Will.” University of Rochester Medical Center, University of Rochester, 2016,
urmc.rochester.edu/MediaLibraries/URMCMedia/jones-memorial/patients-families/documents/living_will_nys.pdf.
New York State Living Will
is Living Will has been prepared to conform to the law in the State of New York, as set forth in
the case In re Westchester County Medical Center, 72 N.Y. 2d 517 (1988). In that case the Court
established the need for “clear and convincing” evidence of a patient’s wishes and stated that the“ideal
situation is one in which the patient’s wishes were expressed in some form of writing, perhaps
a ‘Living Will’.”
, being of sound mind, make this statement as a I, [1]______________________________________________
directive to be followed if I become permanently unable to participate in decisions regarding
my medical care. These instructions reflect my firm and settled commitment to decline medical
treatment under the circumstances indicated below:
I direct my attending physician to withhold or withdraw treatment that merely prolongs
my dying, if I should be in an incurable or irreversible mental or physical condition with no
reasonable expectation of recovery, including but not limited to: (a) a terminal condition; (b)
a permanently unconscious condition; or (c) a minimally conscious condition in which I am
permanently unable to make decisions or express my wishes.
I direct that my treatment be limited to measures to keep me comfortable and to relieve
pain, including any pain that might occur by withholding or withdrawing treatment. While
I understand that I am not legally required to be specific about future treatments if I am in
the condition(s) described above I feel especially strongly about the following forms of
treatment:
[2]
I do not want cardiac resuscitation.
I do not want mechanical respiration.
I do not want artificial nutrition and hydration.
I do not want antibiotics.
However, I do want maximum pain relief, even if it may hasten my death.
[3] Other directions:
These directions express my legal right to refuse treatment, under the law of New York. I intend my
instructions to be carried out, unless I have rescinded them in a new writing or by clearly indicating
that I have changed my mind.
[4]
DateSigned ____________________________________________________________ _____________________________________________
Address_________________________________________________________________________________________________________________
I declare that the person who signed this document appeared to execute the Living Will willingly
and free from duress. He or she signed (or asked another to sign for him or her) this document in my
presence.
[5]
Name of Witness 1 (please print, sign and date)
DateSigned ____________________________________________________________ _____________________________________________
Address_________________________________________________________________________________________________________________
Name of Witness 2
DateSigned ____________________________________________________________ _____________________________________________
Address_________________________________________________________________________________________________________________
