Pennsylvania Living Will Form PDF

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Pennsylvania Living Will Template PDF Free Download

Pennsylvania Living Will

A Pennsylvania living will is a legal document that states the health care treatments a patient (the “principal”) wishes to receive upon losing their ability to communicate.

The terms of the form are related to end-of-life care, life-sustaining procedures, and organ donation.

The principal will outline their health care decisions in Part 2 of the document linked on this page.

If the principal would also like to designate a medical decision maker, or “health care agent,” they may do so by completing the Medical Power of Attorney form found in Part 1 of this document.

Completing both parts of the form creates an Advance Directive for the principal.

Laws – Title 20, Chapter 54, Subchapter B (Living Wills)

Signing Requirements (§ 5442) – Two (2) Witnesses

Statutory Form – § 5471

How to Write

Step 1 – Declarant/Principal End of Life Decisions -This section addresses the decisions made by the Declarant while they are still of sound mind to decide for themselves how they would like their life to end.

Begin by reading the selections provided.

All of the selections will apply unless the Declarant/Principal, writes or types in the words “I DO want” in the line(s) next to any of the selections

If the Declarant/Principal, even though there will be no chance of recovery, would like to have tube-fed nutrition, initial the line stating so.

If no tune feeding is desired, initial the line preceding that option.

Step 2 – Healthcare Agent – If the Declarant/Principal has chosen a Healthcare Agent, they may select whether they wish for the agent to follow their initial instructions or they may select to have the healthcare agent only use the document as guidance as to how they should proceed with any further decision making with regard to the Declarant’s health care.

The Declarant may choose by initialling the line preceding their selection

Step 3 – Legal Protection – The Declarant/Principal must read the information in this section so that they will be clear that their selected agent and the health care providers will be held harmless in the act of good faith in honouring the Declarant’s end of life wishes

Step 4 – Organ Donation – This area will address choices with regard to organ donation.

The Declarant may elect to donate their organs entirely

State-specific donations and how they would like them to be used


Elect not to participate in organ donation at all

Select by initialling the line preceding the selection

Step 5 – Signatures – The Declarant/Principal must enter their dated signature as follows:

Date in dd/mm/yyyy format

The declarant must enter their full legal name (signature) if they opt for health care power of attorney and health care treatment instructions

Witnesses may in no way be related, by a blood relative, marriage, physician, creditor, heir to the Declarant’s estate, employer or the Principal themselves

With all witnesses in the presence of one another, the witnesses must enter their signatures

Step 6 – Notarization – Although notarization is optional in the state of Pennsylvania and not necessary if the Declarant/Principal is in need of this document while in another state for any reason, the laws in other states may be more likely to honour the document with notarization.

If the Declarant/Principal opts, additionally, for notarization, the notary will complete the remainder of the document authenticating with the state seal

Language English
No. of Pages3
PDF Size1 MB

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Pennsylvania Living Will Template PDF Free Download

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