LIVING WILL DECLARATION
**********THIS DOCUMENT IS ONLY A SAMPLE**********
IT MAY NOT CONFORM TO THE LAWS IN YOUR STATE
DISCUSS THIS DOCUMENT WITH YOUR PHYSICIAN(S), FAMILY MEMBERS, FRIENDS
AND CLERGY AND PROVIDE THEM WITH A SIGNED COPY OR A PHOTOCOPY.
I, ____________________________, being of sound mind, willfully and
voluntarily make known my desire that my dying shall not be
artificially prolonged under the circumstances set forth below,
subject to later revocation, and do hereby declare:
If at any time I should have an incurable injury, disease, or illness
certified to be a terminal condition by two physicians who have
personally examined me, one of whom shall be my attending physician,
and the physicians have determined that my death will occur whether
or not life-sustaining procedures are utilized, and where the
application of life-sustaining procedures would serve only to
artificially prolong the dying process, and I am unable to
participate in decisions regarding my medical treatment, I direct
that such procedures be withheld or withdrawn, and that I be
permitted to die naturally with only the administration of medication
or the performance of any medical procedure deemed necessary to
provide me with comfort.
In the absence of my ability to give directions regarding the use of
such life-sustaining procedures, it is my intention that this
declaration shall be honored by my family and physician(s) as the
final expression of my legal right to refuse medical or surgical
treatment and accept the consequences of such refusal.
I understand the full import of this declaration, and I am
emotionally and mentally capable to make this declaration.
This declaration is made this _____ day of __________, 19_______.
My additional instructions, if any, are listed on the reverse side.
______________________________________________
Declarant
The declarant has been personally known to me, and I believe the
declarant to be of sound mind and 18 years or older. The declarant
voluntarily signed this document in my presence. I did not sign the
declarant's signature above for or at the direction of the declarant.
I am 18 years or older and not related to the declarant by blood or
marriage, am not entitled to any portion of the estate of the
declarant either as a legal heir or under any will of declarant or
any addition thereto, and am not directly financially responsible for
declarant's medical care.
______________________________________________
Witness
______________________________________________
Address
______________________________________________
Witness
______________________________________________
Address
SEE 'OPTIONAL ADDITIONAL INSTRUCTIONS' BELOW
This declaration and the 'Optional Additional Instructions' may be
revoked or changed by the declarant at any time.
OPTIONAL ADDITIONAL INSTRUCTIONS
If there is a statement below with which you do not agree, draw a
line through it and add your initials.
The following (or photocopy thereof) is a statement of my treatment
wishes if I lack the capacity to make or communicate decisions
regarding my medical treatment and there is no reasonable expectation
that I will regain a meaningful quality of life.
* I direct all life sustaining procedures be withheld or withdrawn if
I have:
* a terminal condition, or
* a condition, disease or injury without hope of significant
recovery, or
* extreme mental deterioration, or
* other ___________________________________________________
* Life-sustaining procedures I choose to have withheld or withdrawn
include:
* surgery
* heart-lung resuscitation (CPR)
* antibiotics
* mechanical ventilator (respirator)
* tube feeding (food and water delivered through a tube in
the vein, nose, or stomach)
* other ____________________________________________________
* If my physician believes that a certain life sustaining procedure
or other medical treatment may provide me with comfort, relieve pain
or lead to a significant recovery, I direct my physician to try the
treatment for a reasonable period of time. If it does not improve my
condition, provide comfort or relieve pain, I direct the treatment be
withdrawn even if so doing shortens my life.
* I direct I be given medical treatment to relieve pain or to provide
comfort, even if such treatment might shorten my life, suppress my
appetite or my breathing, or be habit-forming.
* A meaningful quality of life means to me that: (This does not need
to be filled in for the instructions to be valid.)
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
* I prefer to live out my last days at home rather than in a hospital
or a nursing home if it is not a burden to my family.
* If any of my tissues or organs would be of value as transplants to
help other people, I freely give my permission for such donation.
* I make other instructions as follows:
____________________________________________________________________
____________________________________________________________________
* I have discussed my wishes with the following person(s) and
authorize my physician to discuss my treatment and this document with
them:
_____________________________________________________________________
name address telephone
_____________________________________________________________________
name address telephone
* I have read these instructions and have given them careful
consideration, and as I have indicated they are in accordance with my
wishes.
Date:_____________________ Signed: ________________________
Declarant
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