Iowa Living Will DeclarationIowa Living Will Declaration
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THE IOWA STATE BAR ASSOCIATION
Official Form No. 122

FOR THE LEGAL EFFECT OF THE USE OF
THIS FORM, CONSULT YOUR LAWYER

DECLARATION RELATING TO USE OF LIFE-SUSTAINING PROCEDURES

DECLARATION
(Living Will)
If I should have an incurable or irreversible condition that will result either in death within a relatively
short period of time or a state of permanent unconsciousness from which, to a reasonable degree of
medical certainty, there can be no recovery, it is my desire that my life not be prolonged by the
administration of life-sustaining procedures. If I am unable to participate in my health care decisions, I
direct my attending physician to withhold or withdraw life-sustaining procedures that merely prolong the
dying process and are not necessary to my comfort or freedom from pain.
YES__ NO__ In the event that medical professionals determine that I may be an organ donor, I
agree to the use of life-sustaining procedures, including a ventilator, for the sole purpose and time
period re