Declaration made this ___ day of __________, 19__ (month, year).
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, do hereby declare:
If at any time I should have an incurable injury, disease, or illness certified to be a terminal 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procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me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 physician(s) 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.
Signed: ______________________
City, County and State of Residence: _________________
Date: ____________________________________
The declarant has been personally known to me and I believe him or her to be of sound mind. I did not sign the declarant's signature above for or at the direction of the declarant. I am not related to the declarant by blood or marriage, entitled to any portion of the estate of the declarant according to the laws of intestate succession or under any will of declarant or codicil thereto, or directly financially responsible for declarant's medical care.
Witness: __________________________________
Witness: __________________________________
Date: __________________________________
ALASKA DECLARATION
If I should have an incurable or irreversible condition that will cause my death within a relatively short time, it is my desire that my life not be prolonged by administration of life-sustaining procedures.
If my condition is terminal and I am unable to participate in decisions regarding my medical treatment, I direct my attending physician, to withhold or withdraw procedures that merely prolong the dying process and are not necessary to my comfort or to alleviate pain.
I [__] do [__] do not desire that nutrition or hydration (food and water) be provided by gastric tube or intravenously if necessary.
Signed this _____ day of __________,19__.
Signature: __________________________
Place: __________________________
The declarant is known to me and voluntarily signed or voluntarily directed another to sign this document in my presence.
Witness: ___________________________
Address: ___________________________
Witness: ___________________________
Address: ___________________________
State of __________
Judicial District __________
The foregoing instrument was acknowledged before me this ___ day of _________ by _____________________________________ .
____________________________________________
Signature of Person Taking Acknowledgment
____________________________________
Title or Rank
_______________________________________
Serial Number, if any
ARIZONA DECLARATION
Declaration made this _____ day of __________, 19__ (month, year).
I, ____________________, 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, and declare that:
If at any time I should have an incurable injury, disease or illness certified to be a terminal condition by two physicians who have personally examined me, one of whom is my attending physician, and the physicians have determined that my death will occur unless life-sustaining procedures are used and if the application of life-sustaining procedures would serve only to artificially prolong the dying process, I direct that life-sustaining procedures be withheld or withdrawn and that I be permitted to die naturally with only the administration of medication, food or fluids or the performance of medical procedures deemed necessary to provide me with comfort care.
In the absence of my ability to give directions regarding the use of life-sustaining procedures, it is my intention that this declaration be honored by my family and attending physician 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 have emotional and mental capacity to make this declaration.
Signed: ____________________________________
City, County, and state of residence ______________________
The declarant is personally known to me and I believe him to be of sound mind.
Witness: ____________________________________
Witness: ____________________________________
ARKANSAS DECLARATION
(TERMINAL CONDITION DECLARATION)
If I should have an incurable or irreversible condition that will cause my death within a relatively short time, and I am no longer able to make decisions regarding my medical treatment, I direct my attending physician, pursuant to the Arkansas Rights of the Terminally Ill or Permanently Unconscious Act, to [withhold or withdraw treatment that only prolongs the process of dying and is not necessary to my comfort or to alleviate pain] [follow the instructions of __________________ whom I appoint as my Health Care Proxy to decide whether life-sustaining treatment should be withheld or withdrawn].
Signed this ____ day of __________________, 19__.
Signature: __________________________
Address: __________________________
The declarant voluntarily signed this writing in my presence.
Witness: ___________________________
Address: ___________________________
Witness: ___________________________
Address: ___________________________
ARKANSAS DECLARATION
(PERMANENTLY UNCONSCIOUS DECLARATION)
If I should become permanently unconscious I direct my attending physician, pursuant to the Arkansas Rights of the Terminally Ill or Permanently Unconscious Act, to [withhold or withdraw life-sustaining treatments that are no longer necessary to my comfort or to alleviate pain][follow the instructions of ________________ whom I appoint as my Health Care Proxy to decide whether life-sustaining treatment should be withheld or withdrawn]. Signed this _____ day of __________,19__.
Signature: __________________________
Address: __________________________
The declarant voluntarily signed this writing in my presence.
Witness: ___________________________
Address: ___________________________
Witness: ___________________________
Address: ___________________________
CALIFORNIA DIRECTIVE TO PHYSICIANS
Directive made this _____ day of __________, 19__. (month, year)
I, ____________________, being of sound mind, willfully and voluntarily make known my desire that my life shall not be artificially prolonged under the circumstances set forth below, do hereby declare:
1. 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.
2. 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 accept the consequences from such refusal.
3. 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.
4. If I have been diagnosed and notified at least 14 days ago as having a terminal condition by ___________________, M.D., whose address is ____________________________, and whose telephone number is _____________________. I understand that if I have not filled in the physician's name and address, it shall be presumed that I did not have a terminal condition when I made out this directive.
5. This directive shall have no force or effect five years from the date filled in above.
6. I understand the full import of this directive and I am emotionally and mentally competent to make this directive.
Signed: ____________________________________
City, County and State of Residence:
______________________________
The declarant has been personally known to me and I believe him or her to be of sound mind.
Witness: ____________________________________
Witness: ____________________________________
COLORADO DECLARATION AS TO MEDICAL OR SURGICAL TREATMENT
I, ____________________, being of sound mind and at least eighteen years of age, direct that my life shall not be artificially prolonged under the circumstances set forth below and hereby declare that:
1. If at any time my attending physician and one other physician certify in writing that:
a. I have an injury, disease, or illness which is not curable or reversible and which, in their judgment, is a terminal condition; and
b. For a period of forty-eight consecutive hours or more, I have been unconscious, comatose, or otherwise incompetent so as to be unable to make or communicate responsible decisions concerning my person; then
I direct that life-sustaining procedures shall be withdrawn and withheld, it being understood that life-sustaining procedures shall not include any medical procedure or intervention for nourishment or considered necessary by the attending physician to provide comfort or alleviate pain.
2. I execute this declaration, as my free and voluntary act, this _____ day of __________, 19___.
By ___________________________ Declarant
The foregoing instrument was signed and declared by ______________________ to be his declaration, in the presence of us, who, in his presence, in the presence of each other, and at his request, have signed our names below as witnesses, and we declare that, at the time of the execution of this instrument, the declarant, according to our best knowledge and belief, was of sound mind and under no constraint or undue influence.
Dated at ______________, Colorado, this _____ day of
__________, 19__.
Name and Address __________________
Name and Address __________________
STATE OF COLORADO )
) ss.
County of _________ )
SUBSCRIBED and sworn to before me by _________________, the declarant, and _____________________, and ____________________, witnesses, as the voluntary act and deed of the declarant, this _____ day of __________, 19___.
My commission expires:
______________________________
Notary Public
CONNECTICUT DECLARATION
If the time comes when I am incapacitated to the point when I can no longer actively take part in decisions for my own life, and am unable to direct my physician as to my own medical care, I wish this statement to stand as a testament of my wishes. I ________________ request that I be allowed to die and not be kept alive through life support systems if my condition is deemed terminal. I do not intend any direct taking of my life, but only that my dying not be unreasonably prolonged. This request is made, after careful reflection, while I am of sound mind.
____________________________ (Signature)
____________________________ (Date)
____________________________ (Witness)
____________________________ (Witness)
DISTRICT OF COLUMBIA DECLARATION
Declaration made this _____ day of __________, 19__ (month, year). 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, do declare:
If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by 2 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 or to alleviate pain.
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 physician(s) 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.
Signed: ____________________________________
Address: ____________________________________
I believe the declarant to be of sound mind. I did not sign the declarant's signature above for or at the direction of the declarant. I am at least 18 years of age and am not related to the declarant by blood or marriage, entitled to any portion of the estate of the declarant according to the laws of intestate succession of the District of Columbia or under any will of the declarant or codicil thereto, or directly financially responsible for declarant's medical care. I am not the declarant's attending physician, an employee of the attending physician, or an employee of the health facility in which the declarant is a patient.
Witness: ____________________________________
Witness: ____________________________________
FLORIDA DECLARATION
Declaration made this _____ day of __________, 19__. I, ____________________, willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do hereby declare:
If at any time I should have a terminal condition and if my attending physician has determined that there can be no recovery from such condition and that my death is imminent, I direct that life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, 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 or to alleviate pain.
I do [___] I do not [___] desire that nutrition and hydration (food and water) be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying.
In the absence of my ability to give directions regarding the use of such life-prolonging procedures, it is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences for such refusal.
If I have been diagnosed as pregnant and that diagnosis is known to my physician, this declaration shall have no force or effect during the course of my pregnancy.
I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration.
________________________
(Signed)
The declarant is known to me, and I believe him or her to be of sound mind.
_______________________
Witness
_______________________
Witness
GEORGIA LIVING WILL
Living will made this _____ day of __________, 19__. I ____________________, being of sound mind, willfully and voluntarily make known my desire that my life shall not be prolonged under the circumstances set forth below and do declare:
1. If at any time I should have a terminal condition as defined in and established in accordance with the procedures set forth in paragraph (10) of Code Section 31-32-2 of the Official Code of Georgia Annotated, I direct that the application of life-sustaining procedures to my body be withheld or withdrawn, and that I be permitted to die;
2. In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this living will shall be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal;
3. I understand that I may revoke this living will at any time;
4. I understand the full import of this living will, and I am at least 18 years of age and am emotionally and mentally competent to make this living will; and
5. If I am female and I have been diagnosed as pregnant, this living will shall have no force and effect during the course of my pregnancy.
I hereby witness this living will and attest that:
(1) The declarant is personally known to me and I believe the declarant to be at least 18 years of age and of sound mind;
(2) I am at least 18 years of age;
(3) To the best of my knowledge, at the time of the execution of this living will, I:
(A) Am not related to the declarant by blood or marriage;
(B) Would not be entitled to any portion of the declarant's estate by any will or by operation of law under the rules of descent and distribution of this state;
(C) Am not the attending physician of declarant or an employee of the attending physician or an employee of the hospital or skilled nursing facility in which declarant is a patient;
(D) Am not directly financially responsible for declarant's medical care; and
(E) Have no present claim against any portion of the estate of the declarant;
(4) Declarant has signed this document in my presence as above instructed, on the date above first shown.
Witness ____________________________________
Address ____________________________________
Witness ____________________________________
Address ____________________________________
(Additional witness when living will is signed in a hospital or skilled nursing facility)
I hereby witness this living will and attest that I believe the declarant to be of sound mind and to have made this living will willingly and voluntarily.
Witness: ____________________________________
Medical Director of skilled nursing facility or staff physician not participating in care of the hospital medical staff or staff physician not participating in care of the patient.
HAWAII DECLARATION
A. Statement of Declarant
Declaration made this _____ day of __________, 19 __.
I, ___________________, 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, and do hereby declare:
If at any time I should have an incurable or irreversible condition certified to be terminal by two physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that I am unable to make decisions concerning my medical treatment, and that without administration of life-sustaining treatment my death will occur in a relatively short time, and where the application of life-sustaining procedures would serve only to prolong artificially 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, nourishment, or fluids or the performance of any medical procedure deemed necessary to provide me with comfort or alleviate pain.
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 physician(s) 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.
Signed: ____________________________________
Address: ___________________________________
B. Statement of Witnesses
I am at least 18 years of age and
-not related to the declarant by blood, marriage, or adoption; and
-not the attending physician, an employee of the attending physician, or an employee of the medical care facility in which the declarant is a patient.
The declarant is personally known to me and I believe the declarant to be of sound mind.
Witness ____________________________________
Address ____________________________________
Witness ____________________________________
Address ____________________________________
C. Notarization
Subscribed, sworn to and acknowledged before me by ___________________, the declarant, and subscribed and sworn to before me by ________________________ and ____________________, witnesses, this ___ day of __________, 19__.
(SEAL)
Signed ______________________________
(Official capacity of officer)
IDAHO
A LIVING WILL
A Directive to Withhold or to Provide Treatment
To my family, my relatives, my friends, my physicians, my employers, and all others whom it may concern:
Directive made this _____ day of __________ 19__ I, ____________________, being of sound mind, willfully and voluntarily make known my desire that my life shall not be prolonged artificially under the circumstances set forth below, do hereby declare:
1. If at any time I should have an incurable injury, disease, illness or condition certified to be terminal by two medical doctors who have examined me, and where the application of life-sustaining procedures of any kind would serve only to prolong artificially the moment of my death, and where a medical doctor determines that my death is imminent, whether or not life-sustaining procedures are utilized, or I have been diagnosed as being in a persistent vegetative state, I direct that the following marked expression of my intent be followed and that I be permitted to die naturally, and that I receive any medical treatment or care that may be required to keep me free of pain or distress.
"Check One Box"
[ ] If at any time I should become unable to communicate my instructions, then I direct that all medical treatment, care, and nutrition and hydration necessary to restore my health, sustain my life, and to abolish or alleviate pain or distress be provided to me. Nutrition and hydration shall not be withheld if I would die from malnutrition or dehydration rather than from my injury, disease, illness or condition.
[ ] If at any time I should become unable to communicate my instructions and where the application of artificial life-sustaining procedures shall serve only to prolong artificially the moment of my death, I direct that such procedures be withheld or withdrawn, with only the administration of nutrition and hydration.
[ ] If at any time I should become unable to communicate my instructions and where the application of artificial life-sustaining procedures shall serve only to prolong artificially the moment of my death, I direct that such procedures be withheld or withdrawn including withdrawal of the administration of nutrition and hydration.
2. In the absence of my ability to give directions regarding the use of life-sustaining procedures, I hereby appoint ___________________ (name) currently residing at __________________________________, as my attorney-in-fact/proxy for the making of decisions relating to my health care in my place; and it is my intention that this appointment shall be honored by him/her, by my family, relatives, friends, physicians and lawyer as the final expression of my legal right to refuse medical or surgical treatment; and I accept the consequences of such a decision. I have duly executed a Durable Power of Attorney for health care decisions on this date.
3. In the absence of my ability to give further directions regarding my treatment, including life-sustaining procedures, it is my intention that this directive shall be honored by my family and physicians as the final expression of my legal right to refuse or accept medical and surgical treatment, and I accept the consequences of such refusal.
4. If I have been diagnosed as pregnant and that diagnosis is known to any interested person, this directive shall have no force during the course of my pregnancy.
5. I understand the full importance of this directive and am emotionally and mentally competent to make this directive. No participant in the making of this directive or in its being carried into effect, whether it be a medical doctor, my spouse, a relative, friend or any other person shall be held responsible in any way, legally, professionally or socially, for complying with my directions.
Signed ____________________________________
City, county and state of residence ______________________________
The declarant has been known to me personally and I believe him/her to be of sound mind.
This declaration is made this _____ day of __________, 19__. I ____________________, being of sound mind, willfully and voluntarily make known my desires that my moment of death shall not be artificially postponed.
If at any time I should have an incurable and irreversible injury, disease, or illness judged to be a terminal condition by my attending physician who has personally examined me and has determined that my death is imminent except for death delaying procedures, I direct that such procedures which would only prolong the dying process be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, sustenance, or the performance of any medical procedure deemed necessary by my attending physician to provide me with comfort care.
In the absence of my ability to give directions regarding the use of such death delaying procedures, it is my intention that this declaration shall be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.
Signed: ____________________________________
City, County and State of Residence:_____________________________
The declarant has been personally known to me and I believe him or her to be of sound mind. I saw the declarant sign the declaration in my presence (or the declarant acknowledged in my presence that he or she had signed the declaration) and I signed the declaration as a witness in the presence of the declarant. I did not sign the declarant's signature above for or at the direction of the declarant. As of the date of this instrument, I am not entitled to any portion of the estate of the declarant according to the laws of intestate succession or, to the best of my knowledge and belief, under any will of declarant or other instrument taking effect at declarant's death, or directly financially responsible for declarant's medical care.
Witness _______________________________________
Witness _______________________________________
INDIANA LIVING WILL DECLARATION
Declaration made this _____ day of __________, 19__.
I, ____________________, being at least eighteen (18) years old and 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 I declare:
If at any time I have an incurable injury, disease, or illness certified in writing to be a terminal condition by my attending physician, and my attending physician has determined that my death will occur within a short period of time, and the use of life-prolonging 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 provision of appropriate nutrition and hydration and the administration of medication and the performance of any medical procedure necessary to provide me with comfort care or alleviate pain.
In the absence of my ability to give directions regarding the use of such life-prolonging procedures, it is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences of the refusal.
I understand the full import of this declaration.
Signed: ____________________________________
City, County and State of Residence: _____________________________
The declarant has been personally known to me, and I believe (him/her) to be of sound mind. I did not sign the declarant's signature above for or at the direction of the declarant. I am not a parent, spouse, or child of the declarant. I am not entitled to any part of the declarant's estate or directly financially responsible for declarant's medical care. I am competent and at least eighteen (18) years old.
Witness: _______________________________
Date: __________________
Witness: _______________________________
Date: __________________
IOWA DECLARATION
If I should have an incurable or irreversible condition that will cause my death within a relatively short time, it is my desire that my life not be prolonged by administration of life-sustaining procedures. If my condition is terminal and I am unable to participate in decisions regarding my medical treatment, I direct my attending physician to withhold or withdraw procedures that merely prolong the dying process and are not necessary to my comfort or freedom from pain
Signed this ____ day of __________________,19__.
Signature:__________________________
City, County & State of Residence __________________________
The declarant is known to me and voluntarily signed this document in my presence.
Witness: ___________________________
Address: ___________________________
Witness: ___________________________
Address: ___________________________
KANSAS DECLARATION
Declaration made this _____ day of __________, 19__.
I, ____________________, 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 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 physician(s) 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.
Signed: ____________________________________
City, County and State of Residence _____________________________
The declarant has been personally known to me and I believe him or her to be of sound mind. I did not sign the declarant's signature above for or at the direction of the declarant. I am not related to the declarant by blood or marriage, entitled to any portion of the estate of the declarant according to the laws of intestate succession or under any will of declarant or codicil thereto, or directly financially responsible for declarant's medical care.
Witness: ____________________________________
Witness: ____________________________________
LOUISIANA DECLARATION
Declaration made this _____ day of _______________, 19.
I, ____________________, 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 and 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 prolong artificially 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 physician(s) 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.
Signed: ____________________________________
City, Parish and State of Residence_______________________________
The declarant has been personally known to me and I believe him or her to be of sound mind.
Witness: ____________________________________
Witness: ____________________________________
MAINE DECLARATION
If I should have an incurable or irreversible condition that will cause my death within a short time, and if I am unable to participate in decisions regarding my medical treatment, I direct my attending physician to withhold or withdraw procedures that merely prolong the dying process and are not necessary to my comfort or freedom from pain.
Signed this _____ day of _____________________________________ date month year
Signature __________________________
City, County and State of Residence______________________________ city county state
The declarant is known to me and voluntarily signed this document in my presence.
Witness: ___________________________
Address: ___________________________
Witness: ___________________________
Address: ___________________________
MARYLAND DECLARATION
On this _____ day of __________, 19__.
I, ____________________, being of sound mind, willfully and voluntarily direct that my dying shall not be artificially prolonged under the circumstances set forth in this declaration:
If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two (2) physicians who have personally examined me, one (1) of whom shall be my attending physician, and the physicians have determined that my death is imminent and will occur whether or not life-sustaining procedures are utilized and where the application of such 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, the administration of food and water, and the performance of any medical procedure that is necessary to provide comfort care or alleviate pain. 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 physician(s) as the final expression of my right to control my medical care and treatment.
I am legally competent to make this declaration, and I understand its full import.
Under penalty of perjury, we state that this declaration was signed by _______________ in the presence of the undersigned who, at ________________ his/her request, in _________________ presence, and in the presence of each other, have hereunto signed our names as witnesses this ____ day of ___________, 19___. Further, each of us, individually states that: The declarant is known to me, and I believe the declarant to be of sound mind. I did not sign the declarant's signature to this declaration. Based upon information and belief, I am not related to the declarant by blood or marriage, a creditor of the declarant, entitled to any portion of the estate of the declarant under any existing testamentary instrument of the declarant, entitled to any financial benefit by reason of the death of the declarant, financially or otherwise responsible for the declarant's medical care nor an employee of any such person or institution.
____________________________________
Address _____________________________
____________________________________
Address _____________________________
MINNESOTA DECLARATION
TO MY FAMILY, DOCTORS, AND ALL THOSE CONCERNED WITH MY CARE:
I, ____________________, being an adult of sound mind, willfully and voluntarily make this statement as a directive to be followed if I am in a terminal condition and become unable to participate in decisions regarding my health care. I understand that my health care providers are legally bound to act consistently with my wishes, within the limits of reasonable medical practice and other applicable law. I also understand that I have the right to make medical and health care decisions for myself as long as I am able to do so and to revoke this declaration at any time.
(1) The following are my feelings and wishes regarding my health care (you may state the circumstances under which this declaration applies):
(4) I particularly want to have the following kinds of life-sustaining treatment If I am diagnosed to have a terminal condition (you may list specific types of life-sustaining treatment that you do want if you have a terminal condition):
(5) I particularly do not want to have the following kinds of life-sustaining treatment if I am diagnosed to have a terminal condition (you may list specific types of life-sustaining treatment that you do not want if you have a terminal condition):
(6) I recognize that if I reject artificially administered sustenance, then I may die of dehydration or malnutrition rather than from my illness or injury. The following are my feelings and wishes regarding artificially administered sustenance should I have a terminal condition (you may indicate whether you wish to receive food and fluids given to you in some other way than by mouth if you have a terminal condition):
(7) Thoughts I feel are relevant to my instructions. (You may, but need not, give your religious beliefs, philosophy, or other personal values that you feel are important. You may also state preferences concerning the location of your care.)
(8) Proxy Designation. (If you wish, you may name someone to see that your wishes are carried out, but you do not have to do this. You may also name a proxy without including specific instructions regarding your care. If you name a proxy, you should discuss your wishes with that person.)
If I become unable to communicate my instructions, I designate the following person(s) to act on my behalf consistently with my instructions, if any, as stated in this document. Unless I write instructions that limit my proxy's authority, my proxy has full power and authority to make health care decisions for me. If a guardian or conservator of the person is to be appointed for me, I nominate my proxy named in this document to act as guardian or conservator of my person.
If the person I have named above refuses or is unable or unavailable to act on my behalf, or if I revoke that person's authority to act as my proxy, I authorize the following person to do so:
I understand that I have the right to revoke the appointment of the persons named above to act on my behalf at any time by communicating that decision to the proxy or my health care provider.
(Sign and date here in the presence of two adult witnesses, neither of whom is entitled to any part of your estate under a will or by operation of law, and neither of whom is your proxy.)
I certify that the declarant voluntarily signed this declaration and that the declarant is personally known to me. I am not named as proxy by the declaration, and to the best of my knowledge, I am not entitled to any part of the estate of the declarant under a will or by operation of law.
DECLARATION made on __________ (date) by ____________________ (person's name) of ______________________ (address), ________________ (Social Security Number).
I, ____________________, being of sound mind, declare that if at any time I should suffer a terminal physical condition which causes me severe distress or unconsciousness, and my physician, with the concurrence of two (2) other physicians, believes that there is no expectation of my regaining consciousness or a state of health that is meaningful to me and but for the use of life-sustaining mechanisms my death would be imminent, I desire that the mechanisms be withdrawn so that I may die naturally. However, if I have been diagnosed as pregnant and that diagnosis is known to my physician, this declaration shall have no force or effect during the course of my pregnancy. I further declare that this declaration shall be honored by my family and my physician as the final expression of my desires concerning the manner in which I die.
Signed: ____________________________________
I hereby witness this declaration and attest that:
(1) I personally know the Declarant and believe the Declarant to be of sound mind.
(2) To the best of my knowledge, at the time of the execution of this declaration, I:
(a) Am not related to the Declarant by blood or marriage,
(b) Do not have any claim on the estate of the Declarant,
(c) Am not entitled to any portion of the Declarant's estate by any will or by operation of law, and
(d) Am not a physician attending the Declarant or a person employed by a physician attending the Declarant.
Witness ____________________________________
Address ____________________________________
Social Security Number ____________________________________
Witness ____________________________________
Address ____________________________________
Social Security Number ____________________________________
MISSOURI DECLARATION
I have the primary right to make my own decisions concerning treatment that might unduly prolong the dying process. By this declaration I express to my physician, family and friends my intent. If I should have a terminal condition it is my desire that my dying not be prolonged by administration of death-prolonging procedures. If my condition is terminal and I am unable to participate in decisions regarding my medical treatment, I direct my attending physician to withhold or withdraw medical procedures that merely prolong the dying process and are not necessary to my comfort or to alleviate pain. It is not my intent to authorize affirmative or deliberate acts or omissions to shorten my life rather only to permit the natural process of dying.
Signed this _____ day of __________,19__.
Signature ________________________________
City, County and State of residence __________________________
The declarant is known to me, is eighteen years of age or older, of sound mind and voluntarily signed this document in my presence.
Witness: ___________________________
Address: ___________________________
Witness: ___________________________
Address: ___________________________
REVOCATION
I hereby revoke the above declaration.
Signed ________________________________ (Signature of Declarant)
Date ________________________________
MONTANA DECLARATION
If I should have an incurable or irreversible condition that will cause my death within a relatively short time, it is my desire that my life not be prolonged by administration of life-sustaining procedures. If my condition is terminal and I am unable to participate in decisions regarding my medical treatment, I direct my attending physician to withhold or withdraw procedures that merely prolong the dying process and are not necessary to my comfort or freedom from pain. It is my intention that this declaration shall be valid until revoked by me.
City, County, and State of Residence _________________________
The declarant is known to me and voluntarily signed this document in my presence.
Witness: ___________________________
Address: ___________________________
Witness: ___________________________
Address: ___________________________
NEVADA DIRECTIVE TO PHYSICIANS
Date ________________________________________
I, ____________________, being of sound mind, intentionally and voluntarily declare:
1. If at any time I am in a terminal condition and become comatose or am otherwise rendered incapable of communicating with my attending physician, and my death is imminent because of an incurable disease, illness or injury, I direct that life sustaining procedures be withheld or withdrawn, and that I be permitted to die naturally.
2. It is my intention that this directive be honored by my family and attending physician as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences of my refusal.
3. If I have been found to be pregnant, and that fact is known to my physician, this directive is void during the course of my pregnancy.
I understand the full import of this directive and I am emotionally and mentally competent to execute it.
Signed ____________________________________
City, County and State of Residence______________________________
The declarant has been personally known to me and I believe __________________ to be of sound mind.
Witness ____________________________________
Witness ____________________________________
NEW HAMPSHIRE DECLARATION
Declaration made this ____ day of __________, 19___.
I, ____________________, 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 condition by 2 physicians who have personally examined me, one of whom shall be my attending physician, and 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, sustenance, 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 right to refuse medical or surgical treatment and accept the consequences of such refusal.
I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration.
Signed ____________________________________
State of __________________________________________
______________________________________ County
We, the declarant and witnesses, being duly sworn each declare to the notary public or justice of the peace or other official signing below as follows:
1. The declarant signed the instrument as a free and voluntary act for the purpose expressed, or expressly directed another to sign for him.
2. Each witness signed at the request of the declarant, in his presence, and in the presence of the other witness.
3. To the best of my knowledge, at the time of signing the declarant was at least 18 years of age, and was of sane mind and under no constraint or undue influence.
____________________________________ Declarant
____________________________________ Witness
____________________________________ Witness
Sworn to and signed before me by ____________________, declarant ____________________ and ____________________ , witnesses on ____________________.
_________________________________
Signature
_________________________________
Official Capacity
NEW MEXICO
No state approved form. However, Living Wills are authorized by statute. See the model form for use in this state.
NORTH CAROLINA
"DECLARATION OF A DESIRE FOR A NATURAL DEATH"
I, ____________________, being of sound mind, desire that my life not be prolonged by extraordinary means if my condition is determined to be terminal and incurable. I am aware and understand that this writing authorizes a physician to withhold or discontinue extraordinary means.
This the _________ day of _____________________________.
Signature __________________________________
I hereby state that the declarant, ____________________, being of sound mind signed the above declaration in my presence and that I am not related to the declarant by blood or marriage and that I do not know or have a reasonable expectation that I would be entitled to any portion of the estate of the declarant under any existing will or codicil of the declarant or as an heir under the Intestate Succession Act if the declarant died on this date without a will. I also state that I am not the declarant's attending physician or an employee of a heath facility in which the declarant is a patient or an employee of a nursing home or any group-care home where the declarant resides. I further state that I do not now have any claim against the declarant.
Witness ____________________________________
Witness ____________________________________
Certificate
I, ____________________, Clerk (Assistant Clerk) of Superior Court or Notary Public (circle one as appropriate) for ____________________ County hereby certify that ____________________, the declarant, appeared before me and swore to me and to the witnesses in my presence that this instrument is his Declaration Of A Desire For A Natural Death, and that he had willingly and voluntarily made and executed it as his free act and deed for the purposes expressed in it.
I further certify that ____________________ and ____________________, witnesses, appeared before me and swore that they witnessed ____________________, declarant, sign the attached declaration, believing him to be of sound mind; and also swore that at the time they witnessed the declaration (i) they were not related within the third degree to the declarant or to the declarant's spouse, (ii) they did not know or have a reasonable expectation that they would be entitled to any portion of the estate of the declarant upon the declarant's death under any will of the declarant or codicil thereto then existing or under the Intestate Succession Act as it provides at that time, and (iii) they were not a physician attending the declarant or an employee of a heath facility in which the declarant was a patient or an employee of a nursing home or any group-care home in which the declarant resided, and (iv) they did not have a claim against the declarant. I further certify that I am satisfied as to the genuineness and due execution of the declaration.
This the _____ day of _____________________________.
____________________________________
Clerk (Assistant Clerk) of the Superior Court
or Notary Public (circle one as appropriate) for the County of __________________________
NORTH DAKOTA DECLARATION
Declaration made this _____ day of _______________ (month year).
I, ____________________, being at least eighteen years of age and of sound mind, willfully and voluntarily make known my desire my life must not be artificially prolonged under the circumstances set forth below, and do hereby declare:
1. If at any time I should have an incurable condition caused by injury, disease, or illness certified to be a terminal condition by two physicians, and where the application of life-prolonging treatment would serve only to artificially prolong the process of my dying and my attending physician determines that my death is imminent whether or not life-prolonging treatment is utilized, I direct that such treatment be withheld or withdrawn, and that I be permitted to die naturally.
2. In the absence of my ability to give directions regarding the use of such life-prolonging treatment, it is my intention that this declaration 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 of that refusal, which is death.
3. If I have been diagnosed as pregnant and this diagnosis is known to my physician, this declaration is not effective during the course of my pregnancy.
4. I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration.
5. I understand that I may revoke this declaration at any time.
Signed ____________________________________
City, County and State of Residence ______________________________
The declarant has been personally known to me and I believe the declarant to be of sound mind. I am not related to the declarant by blood or marriage, nor would I be entitled to any portion of the declarant's estate upon the declarant's death. I am not the declarant's attending physician, a person who has a claim against any portion of the declarant's estate upon declarant's death, or a person directly financially responsible for the declarant's medical care.
Witness ____________________________________
Witness ____________________________________
OKLAHOMA DIRECTIVE TO PHYSICIANS
Directive made this _____ day of ____________________, (month, year).
I, ____________________, being of sound mind and twenty-one (21) years of age or older, willfully and voluntarily make known my desire that my life shall not be artificially prolonged under the circumstances set forth below, and do hereby declare:
1. If at any time I should have an incurable irreversible condition caused by injury, disease, or illness certified to be a terminal condition by two physicians, I direct that life-sustaining procedures be withheld or withdrawn and that I be permitted to die naturally, if the application of life-sustaining procedures would serve only to artificially prolong the moment of my death and my attending physician determines that my death is imminent whether or not life-sustaining procedures are utilized;
2. 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 physicians as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences of such refusal;
3. 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;
4. If I have been diagnosed and notified as having a terminal condition by ___________________, M.D or D.O., whose address is ____________________________, and whose telephone number is _____________________. I understand that if I have not filled in the name and address of the physician, it shall be presumed that I did not have a terminal condition when I made out this directive;
5. This directive shall be in effect until it is revoked;
6. I understand the full import of this directive and I am emotionally and mentally competent to make this directive; and
7. I understand that I may revoke this directive at any time.
Signed ____________________________________
City, County and State of Residence _____________________________
The declarant has been personally known to me and I believe said declarant to be of sound mind. I am twenty-one (21) years of age or older, I am not related to the declarant by blood or marriage, nor would I be entitled to any portion of the estate of the declarant upon the death of said declarant, nor am I the attending physician of the declarant or an employee of the attending physician or a health care facility in which the declarant is a patient, nor am I financially responsible for the medical care of the declarant, or any person who has a claim against any portion of the estate of the declarant upon the death of the declarant.
Witness ____________________________________
Witness ____________________________________
State of Oklahoma
County of __________
Before me, the undersigned authority, on this day personally appeared ________________ (declarant), __________________ (witness) and __________________ (witness) whose names are subscribed to the foregoing instrument in their respective capacities, and, all of said persons being by me duly sworn, the declarant declared to me and to the said witnesses in my presence that said instrument is his or her Directive to Physicians , and that the declarant had willingly and voluntarily made and executed it as the free act and deed of the declarant for the purposes therein expressed.
The foregoing instrument was acknowledged before me this _________ day of __________, 19_____.
Signed ________________________________________ Notary Public in and for ____________ County, Oklahoma
My Commission Expires _________ day of _____________, 19_____.
OREGON DIRECTIVE TO PHYSICIANS
Directive made this _____ day of ____________________, (month, year).
I ____________________, being of sound mind, willfully and voluntarily make known my desire that my life shall not be artificially prolonged under the circumstances set forth below and do hereby declare:
1. If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two physicians, one of whom is the attending physician 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.
2. 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 accept the consequences from such refusal.
3. I understand the full import of this directive and I am emotionally and mentally competent to make this directive.
Signed ____________________________________
City, County and State of Residence: ____________________________ I hereby witness this directive and attest that:
(1) I personally know the Declarant and believe the Declarant to be of sound mind;
(2) To the best of my knowledge, at the time of the execution of this directive, I:
(a) Am not related to the Declarant by blood or marriage,
(b) Do not have any claim on the estate of the Declarant,
(c) Am not be entitled to any portion of the Declarant's estate by any will or by operation of law, and
(d) Am not a physician attending the Declarant, a person employed by a physician attending the Declarant or a person employed by a health facility in which the Declarant is a patient.
(3) I understand that if I have not witnessed this directive in good faith I may be responsible for any damages that arise out of giving this directive its intended effect.
Witness _____________________________
Witness ________________________________
STATE OF SOUTH CAROLINA
DECLARATION OF A DESIRE FOR A NATURAL DEATH
COUNTY OF ___________________
I, ____________________, being at least eighteen years of age and a resident of and domiciled in the City of __________, County of __________, State of South Carolina, make this Declaration this ___ day of __________, 19__.
I willfully and voluntarily make known my desire that no life-sustaining procedures be used to prolong my dying if my condition is terminal, and I declare:
If at any time I should have a condition certified to be a terminal condition by two physicians who have personally examined me, one of whom is my attending physician, and the physicians have determined that my death will occur within a relatively short period of time without the use of life-sustaining procedures and where the application of life-sustaining procedures would serve only to prolong the dying process, I direct that the 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 necessary to provide me with comfort care.
In the absence of my ability to give directions regarding the use of life-sustaining procedures, it is my intention that this Declaration be honored by my family and physicians and any health facility in which I may be a patient as the final expression of my legal right to refuse medical or surgical treatment, and I accept the consequences from the refusal.
I am aware that this Declaration authorizes a physician to withhold or withdraw life-sustaining procedures. I am emotionally and mentally competent to make this Declaration.
THIS DECLARATION MAY BE REVOKED:
(1) BY BEING DEFACED, TORN, OBLITERATED, OR OTHERWISE DESTROYED, IN EXPRESSION OF THE DECLARANT'S INTENT TO REVOKE, BY THE DECLARANT OR SOME PERSON IN THE PRESENCE OF AND BY THE DIRECTION OF THE DECLARANT. REVOCATION BY DESTRUCTION OF ONE OR MORE OF MULTIPLE ORIGINAL DECLARATIONS REVOKES ALL OF THE ORIGINAL DECLARATIONS. THE REVOCATION OF THE OF THE ORIGINAL DECLARATIONS ACTUALLY NOT DESTROYED BECOMES EFFECTIVE ONLY UPON COMMUNICATION TO THE ATTENDING PHYSICIAN. THE ATTENDING PHYSICIAN SHALL RECORD IN THE DECLARANT'S MEDICAL RECORD THE TIME AND DATE WHEN THE PHYSICIAN RECEIVED NOTIFICATION OF THE REVOCATION;
(2) BY A WRITTEN REVOCATION SIGNED AND DATED BY THE DECLARANT EXPRESSING HIS INTENT TO REVOKE. THE REVOCATION BECOMES EFFECTIVE ONLY UPON COMMUNICATION TO THE ATTENDING PHYSICIAN. THE ATTENDING PHYSICIAN SHALL RECORD IN THE DECLARANT'S MEDICAL RECORD THE TIME AND DATE WHEN THE PHYSICIAN RECEIVED NOTIFICATION OF THE WRITTEN REVOCATION;
(3) BY AN ORAL EXPRESSION BY THE DECLARANT OF HIS INTENT TO REVOKE THE DECLARATION. THE REVOCATION BECOMES EFFECTIVE ONLY UPON COMMUNICATION TO THE ATTENDING PHYSICIAN BY THE DECLARANT. HOWEVER, AN ORAL REVOCATION MADE TO THE DECLARANT BECOMES EFFECTIVE UPON COMMUNICATION TO THE ATTENDING PHYSICIAN BY A PERSON OTHER THAN THE DECLARANT IF:
(a) THE PERSON WAS PRESENT WHEN THE ORAL REVOCATION WAS MADE;
(b) THE REVOCATION WAS COMMUNICATED TO THE PHYSICIAN WITHIN A REASONABLE TIME;
(c) THE PHYSICAL OR MENTAL CONDITION OF THE DECLARANT MAKES IT IMPOSSIBLE FOR THE PHYSICIAN TO CONFIRM THROUGH SUBSEQUENT CONVERSATION WITH THE DECLARANT THAT THE REVOCATION HAS OCCURRED.
THE ATTENDING PHYSICIAN SHALL RECORD IN THE PATIENT'S MEDICAL RECORD THE TIME, DATE, AND PLACE OF THE REVOCATION AND THE TIME, DATE, AND PLACE, IF DIFFERENT, OF WHEN HE RECEIVED NOTIFICATION OF THE REVOCATION. TO BE EFFECTIVE AS A REVOCATION, THE ORAL EXPRESSION CLEARLY MUST INDICATE A DESIRE THAT THE DECLARATION NOT BE GIVEN EFFECT OR THAT LIFE-SUSTAINING PROCEDURES BE ADMINISTERED;
(4) BY A WRITTEN, SIGNED, AND DATED REVOCATION OR AN ORAL REVOCATION BY A PERSON DESIGNATED BY THE DECLARANT IN THE DECLARATION, EXPRESSING THE DESIGNEE'S INTENT PERMANENTLY OR TEMPORARILY TO REVOKE THE DECLARATION. THE REVOCATION BECOMES EFFECTIVE ONLY UPON COMMUNICATION TO THE ATTENDING PHYSICIAN BY THE DESIGNEE. THE ATTENDING PHYSICIAN SHALL RECORD IN THE DECLARANT'S MEDICAL RECORD THE TIME, DATE, AND PLACE OF THE REVOCATION AND THE TIME, DATE, AND PLACE, IF DIFFERENT, OF WHEN THE PHYSICIAN RECEIVED NOTIFICATION OF THE REVOCATION. A DESIGNEE MAY REVOKE ONLY IF THE DECLARANT IS INCOMPETENT TO DO SO. IF THE DECLARANT WISHES TO DESIGNATE A PERSON WITH AUTHORITY TO REVOKE THIS DECLARATION ON HIS BEHALF, THE NAME AND ADDRESS OF THAT PERSON MUST BE ENTERED BELOW:
We, _______________ and _______________, the undersigned witnesses to the foregoing Declaration, dated the _____ day of ______________, 19___, being first duly sworn, declare to the undersigned authority, on the basis of our best information and belief, that the Declaration was on that date signed by the declarant as and for his DECLARATION OF A DESIRE FOR A NATURAL DEATH in our presence and we, at his request and in his presence, and in the presence of each other, subscribe our names as witnesses on that date. The declarant is personally known to us, and we believe him to be of sound mind. Each of us affirms that he is qualified as a witness to this Declaration under the provisions of the South Carolina Death With Dignity Act in that he is not related to the declarant by blood or marriage, either as a spouse, lineal ancestor, descendant of the parents of the declarant, or spouse of any of them; nor directly financially responsible for the declarant's medical care; nor entitled to any portion of the declarant's estate upon his decease, whether under any will or as an heir by intestate succession; nor the beneficiary of a life insurance policy of the declarant; nor the declarant's attending physician; nor an employee of the attending physician; nor a person who has a claim against the declarant's decedent's estate as of this time. No more than one of us is an employee of a health facility in which the declarant is a patient. If the declarant is a patient in a hospital or skilled or intermediate care nursing facility at the date of execution of this Declaration at least one of us is an ombudsman designated by the State Ombudsman, Office of the Governor.
____________________________________
Witness
____________________________________
Witness
Subscribed before me by _____________________, the declarant, and subscribed and sworn to before me by ____________________ and ___________________, the witnesses, this ____ day of ________________, 19_____.
Notary Public for ____________________________________
My commission expires: ____________________________________
SEAL
TENNESSEE LIVING WILL
I, ____________________, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, and do hereby declare:
If at any time I should have a terminal condition and my attending physician has determined that there can be no recovery from such condition and my death is imminent, where the application of life-prolonging 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 medications or the performance of any medical procedure deemed necessary to provide me with comfortable care or to alleviate pain.
In the absence of my ability to give directions regarding the use of such life-prolonging procedures, it is my intention that this declaration shall be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences of such refusal.
I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration. In acknowledgment whereof, I do hereinafter affix my signature on this _____ day of __________, 19___.
____________________________________
Declarant
We, the subscribing witnesses hereto, are personally acquainted with and subscribe our names hereto at the request of the declarant, an adult, whom we believe to be of sound mind, fully aware of the action taken herein and its possible consequence.
We, the undersigned witnesses, further declare that we are not related to the declarant by blood or marriage; that we are not entitled to any portion of the estate of the declarant 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 declarant is a patient; and that we are not a person who, at the present time, has a claim against any portion of the estate of the declarant upon his death
____________________________________
Witness
____________________________________
Witness
Subscribed, sworn to and acknowledged before me by ___________________, the declarant, and subscribed and sworn to before me by _______________________ and _______________________, witnesses, this ____ day of _________________, 19___.
_____________________________________
Notary Public
TEXAS DIRECTIVE TO PHYSICIANS
Directive made this _____ day of _______________, 19___.
I ____________________ , being of sound mind, willfully and voluntarily make known my desire that my life shall not be artificially prolonged under the circumstances set forth in this directive.
1. If at any time I should have an incurable condition caused by injury, disease, or illness certified to be a terminal condition by two physicians, and if the application of life-sustaining procedures would serve only to artificially postpone the moment of my death, and if my attending physician determines that my death is imminent whether or not life-sustaining procedures are used, I direct that those procedures be withheld or withdrawn, and that I be permitted to die naturally.
2. In the absence of my ability to give directions regarding the use of those life-sustaining procedures, it is my intention that this directive 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 that refusal.
3. If I have been diagnosed as pregnant and that diagnosis is known to my physician, this directive has no effect during my pregnancy.
4. This directive is in effect until it is revoked.
5. I understand the full import of this directive and I am emotionally and mentally competent to make this directive.
6. I understand that I may revoke this directive at any time.
Signed ____________________________________
(City, County and State of Residence) _________________________
The declarant has been personally known to me and I believe the declarant to be of sound mind. I am not related to the declarant by blood or marriage. I would not be entitled to any portion of the declarant's estate on the declarant's death. I am not the attending physician of the declarant or an employee of the attending physician or a health facility in which the declarant is a patient. I am not a patient in the health care facility in which the declarant is a patient. I have no claim against any portion of the declarant's estate on the declarant's death.
Witness ____________________________________
Witness ____________________________________
UTAH DIRECTIVE TO PHYSICIANS AND PROVIDERS OF MEDICAL SERVICES
This directive is made this _____ day of __________, __________.
1. I, ____________________, being of sound mind, willfully and voluntarily make known my desire that my life not be artificially prolonged by life-sustaining procedures except as I may otherwise provide in this directive.
2. I declare that if at any time I should have an injury, disease, or illness, which is certified in writing to be a terminal condition by two physicians who have personally examined me, and in the opinion of those physicians the application of life-sustaining procedures would serve only to unnaturally prolong the moment of my death and to unnaturally postpone or prolong the dying process, I direct that these procedures be withheld or withdrawn and my death be permitted to occur naturally.
3. I expressly intend this directive to be a final expression of my legal right to refuse medical or surgical treatment and to accept the consequences from this refusal which shall remain in effect notwithstanding my future inability to give current medical directions to treating physicians and other providers of medical services.
4. I understand that the term "life-sustaining procedure" does not include the administration of medication or sustenance, or the performance of any medical procedure deemed necessary to provide comfort care, or to alleviate pain, except to the extent I specify below that any of these procedures be considered life-sustaining.
5. I reserve the right to give current medical directions to physicians and other providers of medical services so long as I am able, even though these directions may conflict with the above written directive that life-sustaining procedures be withheld or withdrawn.
6. I understand the full import of this directive and I am emotionally and mentally competent to make this directive.
City, County and State of Residence ______________________________
We witnesses certify that each of us is 18 years of age or older and each personally witnessed the declarant sign or direct the signing of this directive; that we are acquainted with the declarant and believe him to be of sound mind; that the declarant's desires are as expressed above; that neither of us is a person who signed the above directive on behalf of the declarant; that we are not related to the declarant by blood or marriage nor are we entitled to any portion of declarant's estate according to the laws of intestate succession of this state or under any will or codicil of declarant; that we are not directly financially responsible for declarant's medical care; and that we are not agents of any health care facility in which the declarant may be a patient at the time of signing this directive.
______________________________
Signature of Witness
______________________________
Address of Witness
______________________________
Signature of Witness
______________________________
Address of Witness
VERMONT TERMINAL CARE DOCUMENT
To my family, my physician, my lawyer, my clergyman. To any medical facility in whose care I happen to be. To any individual who may become responsible for my health, welfare or affairs.
Death is as much a reality as birth, growth, maturity and old age-it is the one certainty of life. If the time comes when I, ____________________ , can no longer take part in decisions of my own future, let this statement stand as an expression of my wishes, while I am still of sound mind.
If the situation should arise in which I am in a terminal state and there is no reasonable expectation of my recover, I direct that I be allowed to die a natural death and that my life not be prolonged by extraordinary measures. I do, however, ask that medication be mercifully administered to me to alleviate suffering even though this may shorten my remaining life.
This statement is made after careful consideration and is in accordance with my strong convictions and beliefs. I want the wishes and directions here expressed carried out to the extent permitted by law. Insofar as they are not legally enforceable, I hope that those to whom this will is addressed will regard themselves as morally bound by these provisions.
Signed: ___________________________
Date: ___________________________
Witness: __________________________
Witness: __________________________
Copies of this request have been given to:
________________________________
________________________________
________________________________
VIRGINIA DECLARATION
Declaration made this _____ day of _______________. I, ____________________, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, and do hereby declare:
If at any time I should have a terminal condition and my attending physician has determined that there can be no recovery from such condition and my death is imminent, where the application of life-prolonging 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 or to alleviate pain.
In the absence of my ability to give directions regarding the use of such life-prolonging procedures, it is my intention that this declaration shall be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences of such refusal.
I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration.
________________________________
(Signed)
The declarant is known to me and I believe him or her to be of sound mind.
________________________________
Witness
________________________________
Witness
WASHINGTON DIRECTIVE TO PHYSICIANS
Directive made this _____ day of ____________________, 19____.
I ____________________, being of sound mind, willfully and voluntarily make known my desire that my life 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 directive and I am emotionally and mentally competent to make this directive.
Signed ____________________________________
City, County and State of Residence __________________________
The declarer has been personally known to me and I believe him or her to be of sound mind.
Witness ____________________________________
Witness ____________________________________
WEST VIRGINIA DECLARATION
Declaration 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, do declare:
If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two physicians, who have personally examined me, one of whom is 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 nutrition, medication or the performance of any medical procedure deemed necessary to provide me with comfort, care or to alleviate pain.
In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this declaration be honored by my family and physician(s) 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.
Signed ___________________________________________________
I did not sign the declarant's signature above for or at the direction of the declarant. I am eighteen years of age and am not related to the declarant by blood or marriage, entitled to any portion of the estate of the declarant according to the laws of intestate succession of the State of West Virginia or to the best of my knowledge under any will of declarant or codicil thereto, or directly financially responsible for declarant's medical care. I not the declarant's attending physician, an employee of the attending physician, nor an employee of the health facility in which the declarant is a patient.
Witness ____________________________________
Witness ____________________________________
STATE OF _______________________,
COUNTY OF ______________________, to-wit:
This day, personally appeared before me, the undersigned authority, a Notary Public in and for __________ County, ________ (State), __________________ (witness) and __________________ (witness) who, being duly sworn, say that they are the subscribing witnesses to the declaration of ____________ (declarant), which declaration is dated the ___ day of ________________, 19___; and that on the said date ____________ (declarant), the declarant, signed, sealed, published and declared the same as and for his declaration, in the presence of each other, and in the presence of said declarant, all present at the same time, signed their names as attesting witnesses to said declaration.
Affiants further say that this affidavit is made at the request of ____________ (declarant), declarant, and in his presence, and that ____________ (declarant), at the time the declaration was executed, was in the opinion of affiants, of sound mind and memory, and over the age of eighteen years.
_________________________________________
_________________________________________
Taken, subscribed and sworn to before me by _______________ (witness) and _______________ (witness) this _________ day of _____________, 19_____.
My Commission Expires
___________________________
Notary Public
WISCONSIN DECLARATION
Declaration made this _____ day of __________, 19__.
1. I, ____________________, being of sound mind, willfully and voluntarily state my desire that my dying shall not be artificially prolonged if I have an incurable injury or illness certified to be a terminal condition by 2 physicians who have personally examined me, one of whom is my attending physician, and if the physicians have determined that my death is imminent, so that the application of life-sustaining procedures would serve only to prolong artificially the dying process. Under these circumstances, I direct that life-sustaining procedures be withheld or withdrawn and that I be permitted to die naturally, with only:
a. The continuation of nutritional support and fluid maintenance; and
b. The alleviation of pain by administering medication or other medical procedure.
2. If I am unable to give directions regarding the use of life-sustaining procedures, I intend that my family and physician honor this declaration as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from this refusal.
3. If I have been diagnosed as pregnant and my physician knows of this diagnosis, this declaration has no effect during the course of my pregnancy
4. This declaration takes effect immediately.
I understand this declaration and I am emotionally and mentally competent to make this declaration.
Signed ____________________________________
Address __________________________________
I know the declarant personally and I believe him or her to be of sound mind. I am not related to the declarant by blood or marriage, and am not entitled to any portion of the declarant's estate under any will of the declarant. I am neither the declarant's attending physician, the attending nurse, the attending medical staff nor an employee of the attending physician or of the inpatient health care facility in which the declarant may be a patient and I have no claim against the declarant's estate at this time, except that, if I am not a health care provider who is involved in the medical care of the declarant, I may be an employe (sic) of the inpatient health care facility regardless of whether or not the facility may have a claim against the estate of the declarant.
Witness ____________________________________
Witness ____________________________________
WYOMING DECLARATION
Declaration made this _____ day of _______________, 19___. I, ____________________, 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 other illness certified to be a terminal condition by two (2) physicians who have personally examined me, one (1) 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.
If, in spite of this declaration, I am comatose or otherwise unable to make treatment decisions for myself, I HEREBY designate ____________________ to make treatment decisions for me. In the absence of my ability to give directions regarding the use of life-sustaining procedures, it is my intention that this declaration shall be honored by my family and physician(s) and agent as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from this refusal. I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration.
Signed ____________________________________
City, County and State of Residence ______________________________
The declarant has been personally known to me and I believe him or her to be of sound mind. I did not sign the declarant's signature above for or at the direction of the declarant. I am not related to the declarant by blood or marriage, entitled to any portion of the estate of the declarant according to the laws of intestate succession or under any will of the declarant or codicil thereto, or directly financially responsible for declarant's medical care.
Witness ____________________________________
Witness ____________________________________
MODEL DECLARATION
If I should have an incurable or irreversible condition that will cause my death within a relatively short time, and I am no longer able to make decisions regarding my medical treatment, I direct my attending physician, pursuant to the Uniform Rights of the Terminally Ill Act of this State, to withhold or withdraw treatment that only prolongs the process of dying and is not necessary to my comfort or to alleviate pain.
Signed this ________ day of ____________,19___.
_____________________________
Signature
_____________________________
Address
The declarant voluntarily signed this writing in my presence.
