"Living Will Declaration Form" - Louisiana

The Louisiana Living Will Declaration Form - sometimes confused with an Advance Directive - is crucial for patients looking for more control over the medical treatment they would want in the event of incapacitation. The form was released by the Louisiana Secretary of State on January 1, 2018, and is available for download below.

When a person falls seriously ill with no hope or recovery, arguments concerning artificial life support or certain treatments can arise amongst their family when trying to decide on an outcome. With a signed and legal will with all wishes clearly stated, the patient can make pre-plan all procedures regarding palliative care, life support, and life-sustaining treatment. The paperwork should be given careful thought and be talked about with the patient's family, physician, and health care providers since they will be tasked with implementing the specified wishes and procedures.

A Louisiana Living Will is regulated by § 1151.1(4) of Title 40 (Public Health and Safety). According to the law, the declaration may be written, oral or nonverbal and must be made by the declarant in the presence of two (2) witnesses.

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What Is a Louisiana Living Will?

A Living Will is a legal form that lets all participating parties know about the kind of medical care and palliative care a patient wishes to receive. When creating a will, the individual will be deciding on the types of care that they are willing to receive and the types of medical care they will not be receiving. For example, some people choose to not be resuscitated if they stop breathing while in a coma, while others choose to remain on life support.

An individual can print out a basic Living Will template with or without the assistance of an attorney. The document may be revoked in writing or orally, by either the patient (the person making the will) or by a designated proxy (the person elected to make healthcare-related decisions for the patient).

How to Make a Living Will in Louisiana?

A Louisiana 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 "Living Will Declaration Form" - Louisiana

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STATE OF LOUISIANA
DECLARATION
Declaration made this
day of
,
(month, year).
I,
, being of sound
mind, willfully and voluntarily make known my desire that my dying shall not be artificially
prolonged under the circumstances set forth below and do hereby declare:
If at any time I should have an incurable injury, disease or illness, or be in a continual
profound comatose state with no reasonable chance of recovery, certified to be a terminal and
irreversible condition by two physicians who have personally examined me, one of whom shall
be my attending physician, and the physicians have determined that my death will occur whether
or not life-sustaining procedures are utilized and where the application of life-sustaining
procedure would serve only to prolong artificially the dying process, I direct (initial one only):
That all life-sustaining procedures, including nutrition and hydration, be
withheld or withdrawn so that food and water will not be administered invasively.
That life-sustaining procedures, except nutrition and hydration, be withheld or
withdrawn so that food and water can be administered invasively.
I further direct that I be permitted to die naturally with only the administration of
medication or the performance of any medical procedure deemed necessary to provide me with
comfort care.
In the absence of my ability to give directions regarding the use of such life-sustaining
procedures, it is my intention that this declaration shall be honored by my family and
physician(s) as the final expression of my legal right to refuse medical or surgical treatment and
accept the consequences from such refusal.
I understand the full import of this declaration and I am emotionally and mentally
competent to make this declaration.
Signed
City, Parish, and State of Residence
The declarant has been personally known to me and I believe him or her to be of sound
mind.
Witness
Witness
“LIVING WILL” DECLARATION
(R.S. 40:1151 et. sec.)
INSTRUCTIONS: Per R.S. 40:1151 et. sec., the Secretary of State’s Office has established a registry in which a
person, or his attorney, if authorized by the person to do so, may register the original, multiple original, or a
certified copy of the declaration. The filing fee is $20.00 to register the Declaration and receive a laminated
identification card and ID bracelet. The filing fee for a revocation is $5.00. If a certified copy is requested from
this office, there is an additional fee of $20.00 (per R.S. 49:222(A)). Mail the declaration, with the filing fee, to:
.
Secretary of State, Attn: Elections Services, P.O. Box 94125, Baton Rouge, LA 70804-9125
Rev. 01/2018
STATE OF LOUISIANA
DECLARATION
Declaration made this
day of
,
(month, year).
I,
, being of sound
mind, willfully and voluntarily make known my desire that my dying shall not be artificially
prolonged under the circumstances set forth below and do hereby declare:
If at any time I should have an incurable injury, disease or illness, or be in a continual
profound comatose state with no reasonable chance of recovery, certified to be a terminal and
irreversible condition by two physicians who have personally examined me, one of whom shall
be my attending physician, and the physicians have determined that my death will occur whether
or not life-sustaining procedures are utilized and where the application of life-sustaining
procedure would serve only to prolong artificially the dying process, I direct (initial one only):
That all life-sustaining procedures, including nutrition and hydration, be
withheld or withdrawn so that food and water will not be administered invasively.
That life-sustaining procedures, except nutrition and hydration, be withheld or
withdrawn so that food and water can be administered invasively.
I further direct that I be permitted to die naturally with only the administration of
medication or the performance of any medical procedure deemed necessary to provide me with
comfort care.
In the absence of my ability to give directions regarding the use of such life-sustaining
procedures, it is my intention that this declaration shall be honored by my family and
physician(s) as the final expression of my legal right to refuse medical or surgical treatment and
accept the consequences from such refusal.
I understand the full import of this declaration and I am emotionally and mentally
competent to make this declaration.
Signed
City, Parish, and State of Residence
The declarant has been personally known to me and I believe him or her to be of sound
mind.
Witness
Witness
“LIVING WILL” DECLARATION
(R.S. 40:1151 et. sec.)
INSTRUCTIONS: Per R.S. 40:1151 et. sec., the Secretary of State’s Office has established a registry in which a
person, or his attorney, if authorized by the person to do so, may register the original, multiple original, or a
certified copy of the declaration. The filing fee is $20.00 to register the Declaration and receive a laminated
identification card and ID bracelet. The filing fee for a revocation is $5.00. If a certified copy is requested from
this office, there is an additional fee of $20.00 (per R.S. 49:222(A)). Mail the declaration, with the filing fee, to:
.
Secretary of State, Attn: Elections Services, P.O. Box 94125, Baton Rouge, LA 70804-9125
Rev. 01/2018