New Mexico Living Will Declaration
This Living Will Declaration is made in accordance with the New Mexico Uniform Health-Care Decisions Act. It is a legally binding document that outlines my wishes regarding medical treatment and care in the event that I become unable to communicate or make decisions for myself.
Part I: Personal Information
Name: ___________________________________________________
Date of Birth: ___________________________________________
Address: ________________________________________________
City: ____________________ State: NM Zip Code: ____________
Telephone Number: _______________________________________
Part II: Declaration
I, __________________________, being of sound mind, intentionally and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below. I understand that by this document, I am allowing my physicians to withhold or withdraw treatment that serves only to prolong the process of my dying if I am in a terminal condition or in a state of permanent unconsciousness. I am fully informed of the nature of such treatment and the probable effects and consequences of my decision.
Part III: Treatment Preferences
If I am in a terminal condition or a state of permanent unconsciousness, I direct that:
- Life-sustaining treatment be withheld or withdrawn, except as follows: ___________________________________________________________________________.
- Artificially provided fluids and nutrition be withheld or withdrawn, except for the purposes of keeping me comfortable, or as follows: __________________________________________________________________.
- I wish to designate the following limitations on the powers of my health-care agent, if any: ________________________________________________________________________________________________.
Part IV: Appointment of Health Care Agent
If I am unable to make health care decisions for myself, I designate the following person as my health care agent to make health care decisions for me, including decisions to accept or refuse treatment:
Name of Health Care Agent: ___________________________________
Relationship to Me: __________________________________________
Address of Health Care Agent: _________________________________
City: ____________________ State: NM Zip Code: ________________
Telephone Number: ___________________________________________
Alternate Health Care Agent (If primary is unavailable):
Name of Alternate Health Care Agent: ___________________________
Relationship to Me: ___________________________________________
Address of Alternate Health Care Agent: ________________________
City: ____________________ State: NM Zip Code: _________________
Telephone Number: ____________________________________________
Part V: Signatures
This declaration is to be signed in the presence of two witnesses, who also need to sign and date in agreement.
Signature of Declarant: ____________________________________ Date: ________________
Witness 1 Signature: _____________________________________ Date: ________________
Witness 1 Printed Name: ______________________________________________________
Witness 2 Signature: _____________________________________ Date: ________________
Witness 2 Printed Name: ______________________________________________________
Following are main principles of New Mexico law regarding a living will declaration:
- A living will shall be considered valid if it is signed by the declarant in the presence of two or more adult witnesses who are not related to the declarant by blood or marriage.
- The witnesses should also not have any claim to any portion of the declarant's estate upon death.
- The living will should clearly state the declarant’s wishes regarding the withholding or withdrawal of life-sustaining treatment.
- It is advised that the living will should be reviewed regularly and updates made as necessary to ensure it continues to reflect the declarant’s wishes.