New Mexico Living Will
This Living Will is designed to conform to the New Mexico Uniform Health-Care Decisions Act or any corresponding future state legislation, allowing you, the principal, to specify your health care desires clearly. Please ensure all provided information is complete and accurate to ensure your wishes are honored.
Principal's Information
Full Name: ___________________________________________________
Date of Birth: ________________________________________________
Address: _____________________________________________________
City: ________________________ State: NM Zip Code: __________________
Phone Number: _______________________________________________
Health Care Instructions
In the event that I am incapacitated and unable to communicate my health care preferences directly, I direct that my health care providers and any individuals acting on my behalf adhere to the following instructions:
Life-Sustaining Treatment:
___ I do not want life-sustaining treatment if I am in a terminal condition or a permanently unconscious state and the burdens of the treatment outweigh the benefits.
___ I request that all medically appropriate treatments be used to sustain my life, regardless of my condition or prognosis.
Artificial Nutrition and Hydration:
___ I do not want artificial nutrition (feeding through a tube) if I am in a terminal condition or permanently unconscious, and the burdens of the treatment outweigh the benefits.
___ I want to receive artificial nutrition regardless of my condition or prognosis.
Pain Relief:
___ I wish to receive treatment to relieve pain and discomfort, even if such treatments may shorten my life, subject to my specific instructions below:
Additional instructions: ____________________________________________
Health Care Agent
Should I be unable to make my own health care decisions, I designate the following individual as my health care agent:
Name: _________________________________________________________
Relationship: _________________________________________________
Phone Number: _________________________________________________
If my primary agent is unable, unwilling, or unavailable to act as my health care agent, I designate the following alternate agent:
Name: _________________________________________________________
Relationship: _________________________________________________
Phone Number: _________________________________________________
Organ Donation
Upon my death, I wish to donate:
- ___ Any needed organs or tissues
- ___ Only the following organs or tissues: ___________________________
- ___ I do not wish to donate any organs or tissues
Signature
This document represents my wishes as of this date and supersedes any prior directives. By signing below, I verify that I am mentally competent and understand the contents of this Living Will.
Signature: __________________________________________ Date: ________________
Printed Name: _____________________________________________________________
Witnesses
The principal has declared to me that this document represents their health care directives and that they willingly and voluntarily sign it in my presence:
Witness 1 Signature: _______________________________ Date: ________________
Printed Name: _____________________________________________________________
Address: _________________________________________________________________
Witness 2 Signature: _______________________________ Date: ________________
Printed Name: _____________________________________________________________
Address: _________________________________________________________________