I, __________________________, of __________________________,
being of sound mind, do hereby willfully and voluntarily
make known my desire that my life not be prolonged
under any of the following conditions, and do hereby
further declare:
1. If I should, at any time, have an incurable condition
caused by any disease or illness, or by any accident
or injury, and be determined by any two or more physicians
to be in a terminal
condition whereby the use of "heroic measures"
or the application of life-sustaining procedures would
only serve to delay the moment of my death, and where
my attending physician has determined that my death
is imminent whether or not such "heroic measures"
or life-sustaining measures are employed, I direct
that such measures and procedures be withheld or withdrawn
and that I be permitted to die naturally.
2. In the event of my inability to give directions
regarding the application of life-sustaining procedures
or the use of "heroic measures", it is my
intention that this directive shall be honored by
my family and physicians as my final expression of
my right to refuse medical and surgical treatment,
and my acceptance of the consequences of such refusal.
3. If I have been diagnosed as pregnant and such
diagnosis is known to my physicians, this directive
shall have no force or effect during the course of
my pregnancy.
4. I am mentally, emotionally and legally competent
to make this directive and I fully understand its
import.
5. I reserve the right to revoke this directive
at any time.
6. This directive shall remain in force until revoked.
IN WITNESS WHEREOF, I have hereto set my hand and
seal this _____
day of _________________, 20_____.
_______________________________
Declaration of Witnesses
The declarant is personally known to me and I believe
her to be of sound mind and emotionally and legally
competent to make the herein contained Directive to
Physicians. 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 her decease, nor am
I an attending physician of the declarant, nor an
employee of the attending physician, nor an employee
of a health care facility in which the declarant is
a patient, nor a patient in a health care facility
in which the declarant is a patient, nor am I a person
who has any claim against any portion of the estate
of the declarant upon her death.
_______________________________ _______________________________
_______________________________ _______________________________
_______________________________ ________________________________
NOTICE
The information in this document is designed to
provide an outline that you can follow when formulating
business or personal plans. Due to the variances of
many local, city, county and state laws, we recommend
that you seek professional legal counseling before
entering into any contract or agreement.
