STATUTORY DIRECTIVE TO PHYSICIANS IN CONFORMANCE WITH WASHINGTON

R.CW. 70.122.030

DIRECTIVE TO PHYSICIANS

Directive made this __________ day of ________________

19________. I, ______________, being of sound mind, willfully and

voluntarily make known my desires that my dying shall not be

artificially prolonged under the circumstances set forth below,

and do hereby declare that:

(a) If at any time I should have an incurable injury, disease, or

illness certified to be a terminal condition by two physicians,

and where the application of life-sustaining procedures 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, I direct that such

procedures be withheld or withdrawn, and that I be permitted to

die naturally.

(b) In the absence of my ability to give directions regarding the

use of such life-sustaining procedures, it is my intention that

this directive shall be honored by my family and physician(s) as

the final expression of my legal right to refuse medical or

surgical treatment and I accept the consequences from such

refusal.

(c) If I have been diagnosed as pregnant and that diagnosis is

known to my physician, this directive shall have no force or

effect during the course of my pregnancy.

(d) I understand the full import of this declaration and I am

emotionally and mentally competent to make this directive.

________________________________________

City of residence: ________________

County of residence: ______________

State of residence: _______________

Date: _____________________________

The declarer has been personally known to me and I believe him

or her to be of sound mind.

Witness __________________________________________

Witness __________________________________________

Date: ______________________________