Declaration made this _____ day of __________, 20__. 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withheld or withdrawn when the application of such procedures would serve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water) be withheld or withdrawn when the application of such procedures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
_______________________
