Tennessee Living Will Declaration FormTennessee Living Will Declaration Form
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When I, _________________________________, am dying, I may not be able to speak for myself.

I am signing this paper so my doctor and family will know what I want.
If I am going to die no matter what, I want to die naturally. I only want medical care that will
stop pain and keep me comfortable. I do not want treatment that would only make my dying
take longer. I direct the doctors to not give me (withhold) this kind of care. If this kind of care
is already being given, I direct the doctors to stop (withdraw) it.
This living will is to be used when these 3 things are true:

t I am dying from a medical problem and
t My doctor believes there is no real hope I will get well and
t I will probably die from this medical problem no matter what treatment I get.
Also, if I cannot eat or drink by mouth, I am putting a 4 by what I want:


I DO NOT want to get food or water through a vein or feeding tube.
I DO WANT to get food or water through a vein or feeding tube.