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5860.BLD
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1993-01-06
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#5860
@001 Please state the name of the declarant:
@002 Please state the city where signed:
@003 Please state the county where signed:
@004 Please state the state where signed:
#end control section
#5860
/* Para. 5860: Washington State Living Will*/
STATUTORY DIRECTIVE TO PHYSICIANS IN CONFORMANCE WITH
WASHINGTON R.CW. 70.122.030
DIRECTIVE TO PHYSICIANS
Directive made this __________ day of ________________
19________. I, @001, 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utilized, I direct that such procedures be withheld or withdrawn,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.
________________________________________
@001
City of residence: @002
County of residence: @003
State of residence: @004
Date: _____________________________
The declarer has been personally known to me and I believe
him or her to be of sound mind.
Witness __________________________________________
Witness __________________________________________
Date: ______________________________