Tennessee Living Will
This Living Will is executed pursuant to the laws of the State of Tennessee. It is designed to allow you to express your wishes regarding medical treatment in the event that you become unable to communicate them.
Name of Individual: ________________________________________
Date of Birth: ________________________________________
Address: ________________________________________
City, State, Zip Code: ________________________________________
I, the undersigned, do hereby declare that if I become unable to make my own healthcare decisions, I direct that my healthcare providers follow my wishes as expressed in this document.
In the event that I am diagnosed with a terminal condition or am in a persistent vegetative state, I wish to specify the following:
- Do not resuscitate (DNR) and allow natural death.
- Provide comfort care only, no aggressive treatments.
- Use life-sustaining treatments except in the case of irreversible conditions.
Furthermore, I appoint the following individual as my healthcare agent to make decisions on my behalf if I am unable:
Name of Healthcare Agent: ________________________________________
Address: ________________________________________
City, State, Zip Code: ________________________________________
Phone Number: ________________________________________
If my healthcare agent is not available, I consent for the following individual to act on my behalf:
Alternate Agent’s Name: ________________________________________
Address: ________________________________________
City, State, Zip Code: ________________________________________
Phone Number: ________________________________________
By signing below, I affirm that I understand the content of this Living Will and I execute it voluntarily.
Signed this ______ day of _______________, 20____.
Signature: ________________________________________
Witnesses:
- Witness 1: __________________________ Date: ______________
- Witness 2: __________________________ Date: ______________
It is important to keep a copy of this document in a safe place and provide copies to your healthcare agent, family, and healthcare providers.