Dementia-Specific Living Will
Full Legal Name:
Date of Birth:
Address:
Introduction & Purpose
Quality of Life Preferences
Medical Treatment Preferences
If I am in an advanced stage of dementia, I do/do not want the following treatments:
Pain Management:
Artificial Nutrition and Hydration (Feeding Tubes):
Resuscitation:
Hospitalization or Transfers:
Personal & Spiritual Preferences
Other Directions or Requests
Health Care Proxy / Decision-Maker
Name:
Contact Information:
Relationship to Me:
Signatures
Signature
Date
Witness Signature
Date