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Kentucky Advance Directive Form

A Kentucky advance directive is a form that allows a resident of Kentucky to choose another person to make healthcare decisions for them should they become unable to do so for themselves. The designated person, known in Kentucky as a healthcare surrogate, has the power to make important treatment decisions. These can range from electing or refusing treatments that prolong life to deciding whether to donate organs after death.

Signing Requirements (§ 311.625(2)) – Two (2) or more adult witnesses in the presence of the declarant and in the presence of each other or a notary public. Witnesses must not be a blood relative of the declarant, a beneficiary of the declarant, an employee of the healthcare facility where the declarant is a patient, an attending physician, or financially responsible for the declarant’s healthcare.

Statutory Form

Living Will Directive

My wishes regarding life-prolonging treatment and artificially provided nutrition and hydration to be provided to me if I no longer have decisional capacity, have a terminal condition, or become permanently unconscious have been indicated by checking and initialing the appropriate lines below. By checking and initialing the appropriate lines, I specifically:

Designate [NAME] as my health care surrogate(s) to make health care decisions for me in accordance with this directive when I no longer have decisional capacity. If [NAME] refuses or is not able to act for me, I designate [NAME] as my health care surrogate(s).

Any prior designation is revoked.

If I do not designate a surrogate, the following are my directions to my attending physician. If I have designated a surrogate, my surrogate shall comply with my wishes as indicated below:

  • [INITIALS] Direct that treatment be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical treatment deemed necessary to alleviate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.
  • [INITIALS] DO NOT authorize that life-prolonging treatment be withheld or withdrawn.
  • [INITIALS] Authorize the withholding or withdrawal of artificially provided food, water, or other artificially provided nourishment or fluids.
  • [INITIALS] DO NOT authorize the withholding or withdrawal of artificially provided food, water, or other artificially provided nourishment or fluids.
  • [INITIALS] Authorize my surrogate, designated above, to withhold or withdraw artificially provided nourishment or fluids, or other treatment if the surrogate determines that withholding or withdrawing is in my best interest; but I do not mandate that withholding or withdrawing.
  • [INITIALS] Authorize the giving of all or any part of my body upon death for any purpose specified in KRS 311.1929.
  • [INITIALS] DO NOT authorize the giving of all or any part of my body upon death.

In the absence of my ability to 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 any surrogate designated pursuant to this directive as the final expression of my legal right to refuse medical or surgical treatment and I accept the consequences of the refusal.

If I have been diagnosed as pregnant and that diagnosis is known to my attending physician, this directive shall have no force or effect during the course of my pregnancy.

I understand the full import of this directive and I am emotionally and mentally competent to make this directive.

Signed this [DAY] day of [MONTH], 20[XX].

_______________________________
Signature and address of the grantor.

In our joint presence, the grantor, who is of sound mind and eighteen (18) years of age, or older, voluntarily dated and signed this writing or directed it to be dated and signed for the grantor.

_______________________________ [ADDRESS, CITY, STATE, ZIP CODE]
Signature and address of witness.

_______________________________ [ADDRESS, CITY, STATE, ZIP CODE]
Signature and address of witness.