Cancer-Specific Living Will Template
Personal Information
Full Name
Date of Birth
Address
Diagnosis Details
Type and Stage of Cancer
Oncologist/Physician Name
Physician Contact Information
Treatment Preferences
Specific Cancer Treatments I wish to accept or refuse (e.g., chemotherapy, radiation, surgery)
Willingness to Participate in Clinical Trials
Advance Directives
Preferences regarding life support (ventilation, feeding tubes, etc.)
Do Not Resuscitate (DNR) Orders
Pain Management Preferences
Palliative and Hospice Care
Preferences for Palliative or Hospice Care
Preferred Location of Care (home, hospital, hospice facility, etc.)
Healthcare Proxy/Agent
Name of Healthcare Proxy/Agent
Contact Information for Proxy/Agent
Additional Instructions or Wishes
Signatures
Signature
Date
Witness Signature
Date