Questionnaire to Help You Prepare
to See Your Attorney about a Living Will

Main Menu Table of Contents Copyright Disclaimer Questionnaires FCS Home Page Elder Law Section Contributing Attorneys Related Links NC General Assembly

To help you prepare to see your attorney, you may use the following questionnaire to compile information your attorney will need to help you develop an estate plan. Your attorney may prefer to use other questionnaires and may need additional information. Call your attorney before your appointment to see what information he or she may need. You may use the following questionnaire, either by typing your answers directly on the screen or by printing a blank copy and filling out the hard copy. If you choose to type in your answers directly on the screen, print a copy when you are finished. Exiting the program will lose any information you have typed into the questionnaire. Do not try to save your answers in a file because your answers will be erased in the saved file. You will not be asked to transmit your answers over the phone line, so your answers are as secure as your computer. Tip: Print the file often to make sure that you do not lose the information you have entered.

A living will is a declaration that you desire to die a natural death. It allows you to decide in advance that you do not want extraordinary medical treatment or feeding tubes used to keep you alive if there is no reasonable hope of recovery. Making this decision in advance is important because you may not be competent or able to communicate at the time the decision must be made. If you do not have a living will, someone else may have to decide for you. Usually, your doctor and your family will make the decision. A living will relieves your family from making a difficult decision at a stressful and anxious time.

1. Do you want a living will?

Yes No

If you answered "yes," please provide the following information:

2. Full name and address (including county of residence):

Name:
Address:
City, State:
Zip:
County of Residence:

Note: Clicking Reset will erase the above information.

3. When you sign your living will, you must initial some choices. To help you make those choices, please answer the following questions.

a. Do you want to be kept alive by extraordinary means if you are terminally and incurably ill?

Yes No

b. Do you want to be kept alive by artificial nutrition or hydration if you are terminally and incurably ill?

Yes No

c. Do you want to be kept alive by extraordinary means if you are diagnosed as being in a persistent vegetative state?

Yes No

d. Do you want to be kept alive by artificial nutrition or hydration if you are diagnosed as being in a persistent vegetative state?

Yes No

4. Have you signed a living will before?

Yes No Not sure

5. Definition of terms.

• Artificial nutrition or hydration describes the use of feeding tubes or other invasive means to give someone food or water.
• Extraordinary means includes any medical procedure that artificially postpones the moment of death by supporting or replacing a vital bodily function.
• You are considered to be in a persistent vegetative state if you have had a complete, sustained loss of self-aware cognition, and you will die soon without the use of extraordinary means or artificial nutrition or hydration.

---

Prepared by Carol A. Schwab, J.D., LL.M.
Professor and Extension Specialist, NC State University.

This publication is provided as a public service and is designed to acquaint you with certain legal issues and concerns. It is not designed as a substitute for legal advice, nor does it tell you everything you may need to know about this subject. Future changes in the law cannot be predicted, and statements in this publication are based solely on the laws in force on the date of publication.

Date: August 2000

NC State University College of Agriculture and Life Sciences North Carolina Cooperative Extension Service Department of Family and Consumer Sciences

North Carolina Bar Association Elder Law Section

Employment and program opportunities are offered to all people regardless of race, color, national origin, sex, age, or disability.