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Tennessee Living Will Form (Advance Directive) |
The Tennessee Living Will provides the patient with the chance to consider the health care they receive at a time when they are seriously ill, such as being permanently unconscious or suffering mental impairment. The will is created according to the US statutes §§32-11-101 to 32-11-113 and requires two witnesses with the option of a notary. The principal has the right to revoke the will at any time and to enter details of any specific wishes or limitations regarding healthcare.
How to Write
Advanced Directive And Living Will
Advance Care Plan
The principal must enter their name, the details of the agent and an alternative agent.
- Principal`s name.
- Agent`s name.
- Agent`s address.
- Agent`s telephone number.
- Relation of agent to principal.
Quality Of Life
The principal must check any of the boxes they feel are unacceptable with regards to their quality of life through medical care.
- Permanent unconsciousness.
- Permanent confusion.
- Dependent in all activities of daily life.
- End stage illness.
Treatment
The principal must check one of the boxes either `Yes` or `No` to state whether they will require a specific treatment if their quality of life becomes unacceptable or is irreversible.
- Cardiopulmonary resuscitation (CPR).
- Life support/Artificial support.
- Treatment of new conditions.
- Tube feeding / IV fluids.
Other Instructions
The principal may enter details of any other instructions or wishes they have regarding their medical health care treatment.
Organ Donation (Optional)
The principal must check the relevant box and/or enter specific details with respects to their wishes regarding an anatomical donation.
- Donate any organ or tissue.
- Donate whole body.
- Donate specific named items.
Signature
The principal and witnesses and notary must enter their details.
- Principals signature.
- Date.
- Witnesses signatures.
- County.
- Date of expiration of commission.
- Signature of notary.
Appointment Of Health Care Agent
The details of the principal, agent,alternative agent, witnesses and notary must be entered.
- Name.
- Address.
- ZIP code.
- Home/Work/Mobile telephone numbers.
- Principals name.
- Principal`s signature.
- Date.
- Witnesses signatures.
- County.
- Date of expiration of commission.
- Signature of notary.
