Advance Healthcare Directive - Living Will - Canadian Online Legal Document Generator

Statement of Values and Beliefs

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Treatment Directions and End-of-Life Decisions

Terminal Condition

If my condition is determined to be terminal and with no hope of recovery, I would like the following done:

Life Support:

Tube Feeding:

Cardio-Pulmonary Resuscitation:

Intervening Illness:

Persistent Unconsciousness

If I am persistently unconscious with no hope of recovery, I would like the following done:

Life Support:

Tube Feeding:

Cardio-Pulmonary Resuscitation:

Intervening Illness:

Severe and Permanent Mental Impairment

If I am severely and permanently mentally impaired, I would like the following done:

Life Support:

Tube Feeding:

Cardio-Pulmonary Resuscitation:

Intervening Illness:

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Comfort and Dignity

Include the following statement in my Living Will regarding behavior controlling drugs:

If I am suffering from one of the above-mentioned conditions and if my behaviour becomes violent or is otherwise degrading, I want my symptoms to be controlled with appropriate drugs, even if that would worsen my physical condition or shorten my life.

Yes No

Include the following statement in my Living Will regarding pain controlling drugs:

If I am suffering from one of the above mentioned conditions and I appear to be in pain, I want my symptoms to be controlled with appropriate drugs, even if that would worsen my physical condition or shorten my life.

Yes No

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Other Treatments

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Canadian Advance Healthcare Directive - Living Will

Statement of Values and Beliefs

Type your Advance Statement of values and beliefs here:

Treatment Directions and End-of-Life Decisions

Terminal Condition

Persistent Unconsciousness

Severe and Permanent Mental Impairment

Comfort and Dignity

Include the following statement in my Living Will regarding behavior controlling drugs:

Include the following statement in my Living Will regarding pain controlling drugs:

Other Treatments

Do you have strong feelings about certain kinds of treatment you wish to express in your Living Will?

Indicate your consent or refusal to each of the following treatments:

Do you have strong feelings about other treatments that you wish to express in your Personal Directive?

Give additional instructions about any potential treatment that concerns you:

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