Iowa Living Will
This Living Will is made in accordance with Iowa state law. It expresses your wishes regarding medical treatment in the event that you become unable to communicate those wishes yourself.
Personal Information
- Name: ______________________
- Date of Birth: _______________
- Address: ____________________
- City: ________________________
- State: ______________________
- ZIP Code: _____________________
Declarant's Wishes
If I am diagnosed with a terminal condition or a permanently unconscious state, I wish to provide the following instructions regarding my medical care:
- If I am unable to make medical decisions, I do not want life-sustaining treatment, including artificial nutrition and hydration, if:
- My condition is irreversible, or
- There is no reasonable expectation of recovery.
- If I am in a state of persistent unconsciousness, I do not wish to receive treatments that will prolong the dying process.
- I consent to receive only comfort care to keep me comfortable in my final days.
Designated Health Care Agent
I designate the following person as my health care agent:
- Name: ______________________
- Phone Number: ______________
- Address: ____________________
This agent is authorized to make health care decisions on my behalf if I am unable to do so. I trust that they will act in my best interests and according to my wishes.
Signature
By signing below, I affirm that I am of sound mind and understand the nature of this Living Will:
- Signature: _____________________
- Date: _________________________
Witnesses
Two witnesses must sign below to confirm that this Living Will was signed voluntarily and that the declarant appeared to be of sound mind.
- Witness 1: ____________________
- Date: ________________________
- Witness 2: ____________________
- Date: ________________________