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Complete Home and Office Legal Guide (Chestnut) (1993).ISO
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1993-08-01
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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procedures be withheld or withdrawn, and that I be permitted to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: ______________________________