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5550.BLD
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1992-08-31
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#5550
@001 Please state the name of the declarant:
@002 Please state the city where signed:
@003 Please state the parish where signed:
@004 Please state the state where signed:
#end control section
#5550
/* Louisiana Living Will Form */
STATUTORY DECLARATION IN CONFORMANCE WITH LOUISIANA NATURAL DEATH
ACT, LOUISIANA R.S. 40:1299.58.3
DECLARATION OF @001
Declaration made this __________ day of ________________
19________.
I @001, 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, do hereby declare:
If at any time I should have an incurable injury,
disease, or illness certified to be a terminal and irreversible
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, 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withheld or withdrawn, and that I be permitted to die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 care.
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 physicians as the final expression of my legal right
to refuse medical or surgical treatment and accept the
consequences from such refusal.
I understand the full import of this declaration and
I am emotionally and mentally competent to make this
declaration.
________________________________________
@001
City of residence: @002
Parish of residence: @003
State of residence: @004
Date: __________________________________
The declarant has been personally known to me and
I believe him or her to be of sound mind.
Witness _________________________________________________
Witness _________________________________________________
Date: _________________________