Nebraska Living Will Declaration Form
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Nebraska Living Will Declaration
If I should lapse into a persistent vegetative state or have an incurable and irreversible
condition that, without the administration of life-sustaining treatment, will, in the opinion of my
attending physician, cause my death within a relatively short time and I am no longer able to
make decisions regarding my medical treatment, I direct my attending physician, pursuant to
the Rights of the Terminally Ill Act, to withhold or withdraw life-sustaining treatment that is not
necessary for my comfort or to alleviate pain.
Other directions: __________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Signed this _____ day of ________________________
Signature _______________________________
Address _______________________________