"Indiana Living Will Declaration" - Indiana

State Form 55316, Indiana Living Will Declaration - sometimes confused with an Advance Directive - is a vital piece of paperwork that allows all patients to ensure that their wishes regarding life-sustaining medical treatment are honored by doctors and healthcare professionals working in the state of Indiana. Living Will forms are legal tools used to assure that the patient's wishes with respect to the number and quality of medical procedures are carried out in their final days or when they are incapacitated.

The form was released by the Indiana State Department of Health on June 1, 2013. A fillable State Form 55316 can be downloaded through the link below.

An Indiana Living Will is defined by Indiana Code Title 16 (Health) Chapter 4 on wills and life-prolonging procedures. The will must be voluntary, in writing, dated, and signed by the person making the declaration in the presence of at least two (2) adult witnesses. This document is not valid in Indiana if the patient is pregnant.

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What Is an Indiana Living Will?

A Living Will is a document used if a patient is for any reason unable to express their decisions and desires related to end-of-life medical care. The will comes into effect when a person is incapacitated to the point where they are no longer able to actively take part in making the decisions for their own life or unable to direct their physician to do so.

An individual has the right to print a will with the objective to give it to the medical personnel in order to inform them about the type of care they wish to have or wish to avoid in situations of terminal illnesses or incapacitation.

How to Make a Living Will in Indiana?

An Indiana Living Will template commonly includes the kinds of medical procedures administered to patients who are seriously ill. These include the following:

  • The transfusion of blood and blood products;
  • Cardiopulmonary resuscitation;
  • Diagnostic tests;
  • Dialysis;
  • The administration of drugs - specifically pain medication, food, and water;
  • Tissue and organ donation;
  • The use of a respirator;
  • Surgery.

A patient has to print out their will in several copies. It is recommended to keep the original with the other important paperwork where a family member or agent may expect to find them. The copies of the Living Will must be handed out to the medical professionals and relatives tasked with either administering the treatment or executing the will.

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Download "Indiana Living Will Declaration" - Indiana

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INDIANA LIVING WILL DECLARATION
State Form 55316 (6-13)
Indiana State Department of Health – IC 16-36-4
This declaration is effective on the date of execution and remains in effect until revocation or the
death of the declarant. This declaration should be provided to your physician.
LIVING WILL DECLARATION
Declaration made this
day of
(month, year). I,
,
being at least eighteen (18) years of age and of sound mind, willfully and voluntarily make known my desires that my
dying shall not be artificially prolonged under the circumstances set forth below, and I declare:
If at any time my attending physician certifies in writing that:
(1) I have an incurable injury, disease, or illness;
(2) my death will occur within a short time; and
(3) the use of life prolonging procedures would serve only to artificially prolong the dying process,
I direct that such procedures be withheld or withdrawn and that I be permitted to die naturally with only the
performance or provision of any medical procedure or medication necessary to provide me with comfort care or to
alleviate pain, and, if I have so indicated below, the provision of artificially supplied nutrition and hydration.
(Indicate your choice by initialing or making your mark before signing this declaration.):
__________ I wish to receive artificially supplied nutrition and hydration, even if the effort to sustain
life is futile or excessively burdensome to me.
__________ I do not wish to receive artificially supplied nutrition and hydration, if the effort to sustain
life is futile or excessively burdensome to me.
__________ I intentionally make no decision concerning artificially supplied nutrition and hydration,
leaving the decision to my health care representative appointed under IC 16-36-1-7 or
my attorney in fact with health care powers under IC 30-5-5.
In the absence of my ability to give directions regarding the use of life prolonging procedures, it is my intention that
this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or
surgical treatment and accept the consequences of the refusal.
I understand the full import of this declaration.
Signed
City, County, and State of Residence
WITNESSES
The declarant has been personally known to me and I believe (him/her) to be of sound mind. I did not sign the
declarant's signature above for or at the direction of the declarant. I am not a parent, spouse, or child of the
declarant. I am not entitled to any part of the declarant's estate or directly financially responsible for the declarant's
medical care. I am competent and at least eighteen (18) years of age.
Witness __________________________________ Date (month, day, year) _____________________
Witness __________________________________ Date (month, day, year) _____________________
Reset Form
INDIANA LIVING WILL DECLARATION
State Form 55316 (6-13)
Indiana State Department of Health – IC 16-36-4
This declaration is effective on the date of execution and remains in effect until revocation or the
death of the declarant. This declaration should be provided to your physician.
LIVING WILL DECLARATION
Declaration made this
day of
(month, year). I,
,
being at least eighteen (18) years of age and of sound mind, willfully and voluntarily make known my desires that my
dying shall not be artificially prolonged under the circumstances set forth below, and I declare:
If at any time my attending physician certifies in writing that:
(1) I have an incurable injury, disease, or illness;
(2) my death will occur within a short time; and
(3) the use of life prolonging procedures would serve only to artificially prolong the dying process,
I direct that such procedures be withheld or withdrawn and that I be permitted to die naturally with only the
performance or provision of any medical procedure or medication necessary to provide me with comfort care or to
alleviate pain, and, if I have so indicated below, the provision of artificially supplied nutrition and hydration.
(Indicate your choice by initialing or making your mark before signing this declaration.):
__________ I wish to receive artificially supplied nutrition and hydration, even if the effort to sustain
life is futile or excessively burdensome to me.
__________ I do not wish to receive artificially supplied nutrition and hydration, if the effort to sustain
life is futile or excessively burdensome to me.
__________ I intentionally make no decision concerning artificially supplied nutrition and hydration,
leaving the decision to my health care representative appointed under IC 16-36-1-7 or
my attorney in fact with health care powers under IC 30-5-5.
In the absence of my ability to give directions regarding the use of life prolonging procedures, it is my intention that
this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or
surgical treatment and accept the consequences of the refusal.
I understand the full import of this declaration.
Signed
City, County, and State of Residence
WITNESSES
The declarant has been personally known to me and I believe (him/her) to be of sound mind. I did not sign the
declarant's signature above for or at the direction of the declarant. I am not a parent, spouse, or child of the
declarant. I am not entitled to any part of the declarant's estate or directly financially responsible for the declarant's
medical care. I am competent and at least eighteen (18) years of age.
Witness __________________________________ Date (month, day, year) _____________________
Witness __________________________________ Date (month, day, year) _____________________