DIRECTIVE TO PHYSICIANS AS PROVIDED BY IDAHO NATURAL DEATH ACT,

IDAHO CODE SECTION 39-4504

DIRECTIVE TO PHYSICIANS

Directive made this _________________ day of ___________. I

_____________________, being of sound mind, willfully and

voluntarily make known my desire that my life shall not be

artificially prolonged under the circumstances below:

1. In the absence of my ability to give directions regarding the

use of artificial life-sustaining procedures as result of the

disease process of my terminal condition, it is my intention that

such artificial life-sustaining procedures should not be used when

they would serve only to artificially prolong the moment of my

death and where my physician determines that my death is imminent

whether or not life-sustaining procedures are utilized.

2. I have been diagnosed and notified that I have a terminal

condition known as _____________ by ___________ whose address is

___________________, and whose telephone number is ____________.

3. This directive shall have no force and effect five years from

the date filled in above.

4. I understand the full import of this directive and I am

emotionally and mentally competent to make this directive.

Signed _________________________________________________

STATE OF IDAHO

COUNTY OF _________

We, _________________________, _______________________ ,

and _____________________________, the qualified patient and the

witnesses respectively, who names are signed to the attached and

foregoing instrument, being first duly sworn, do hereby declare to

the undersigned authority that the qualified patient signed and

executed the directive and the he signed willingly and he executed

it as his free and voluntary act for the purposes therein

expressed; and that each of the witnesses, in the presence and

hearing of the qualified patient signed the directive as witness

and that to the best of his knowledge the qualified patient was at

the time 18 or more years of age, of sound mind and under no

constraint or undue influence. We the undersigned witnesses

further declare that we are not related to the qualified patient

by blood or marriage; that we are not entitled to any portion of

the estate of the qualified patient upon his decease under any

will or codicil thereto presently existing or by operation of law

then existing; that we are not the attending physician, an

employee of the attending physician or a health facility in which

the qualified patient is a patient, and that we are not a person

who has a claim against any portion of the estate of the qualified

patient upon his decease at the present time.

________________________________________________

Qualified Patient

Subscribed, sworn to and acknowledged before me by

_______________________, the qualified patient, and subscribed

and sworn to before me by ______________________________________

and _____________________, witnesses, this ______________ day of

______________________, 19_______.

________________________________________________

Notary Public for the State of Idaho

Residing at __________________________, Idaho