{This document is a sample of A LIVING WILL WITH ADVANCE DIRECTIVE.  If properly executed it would be valid for both Tennessee and Kentucky.  However, there are choices you must make depending on whether you live in Tennessee or Kentucky.  Where a choice must be made on the basis of residence the choices will be bracketed by parenthesis.  Where there are other choices that must be made with regard to substantive matters those choices will be designated and bracketed by brackets.}

I, {name}, and adult resident citizen of the (State of Tennessee) (Commonwealth of Kentucky), County of {county name} do hereby make this my (Living Will with Advance Directive in accord with Tennessee Law)  (Living Will Directive with a health care Surrogate in accordance with Kentucky Revised Statutes 311.623 and 311.625.)

I appoint {name} as my health care (Surrogate (Kentucky)) (Agent for healthcare decisions (Tennessee)) who in the event I no longer have decisional capacity, is hereby authorized to make health care decisions for me in accordance with the directives herein stated.

It is my wish, desire and will that my health care (Agent) (Surrogate) and or my attending physician comply with the directives stated herein regarding the use or employment of any life-prolonging treatment or artificially provided nutrition and hydration that might be provided to me if I no longer have decisional capacity, have a terminal condition, or become permanently unconscious, those directives being as follows, to wit:

1.      I direct that treatment be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical treatment deemed necessary to alleviate pain.

{2.     I direct that artificially provided food, water or other artificially provided nourishment or fluids be withheld or withdrawn.}

{2. ALTERNATIVE- I authorize my Surrogate, designated above to withhold or withdraw artificially provided nourishment or fluids, or other treatment if my Surrogate determines that withholding or withdrawing is in my best interest; but I do not mandate the withholding or withdrawing.}

In the absence of my ability t give directions regarding the use of life-prolonging treatment and artificially provided nutrition and hydration, it is my intention that this directive shall be honored by my attending physician, my family, and my (Agent) (Surrogate) as my final expression of my legal right to refuse medical or surgical treatment, and I accept the consequences of the refusal.

I understand the full import of this directive and I am emotionally and mentally competent to make this directive.  Signed this _________________ day of __________________ 200_.

                                                (Signature)

(State of Tennessee)

(Commonwealth of Kentucky)

County of________________

Before me, the undersigned authority, came _______________________ who after proper identification, who is above the age of eighteen years, and who appeared to be is of sound mind acknowledged that the forgoing document was voluntarily dated and for the purposes set forth therein.  Done this __________ day of __________ 200_.

      __________________

Notary Public