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such measures and procedures be withheld or withdrawn and that I be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. I am mentally, emotionally and legally competent to make this directive
and I fully understand its import.
4. I reserve the right to revoke this directive at any time.
5. This directive shall remain in force until revoked.
IN WITNESS WHEREOF, I have hereto set my hand and seal this _____ day of
__________, 20___.
Signed: __________
Declaration of Witnesses
The declarant is personally known to me and I believe him to be of sound
mind and emotionally and legally competent to make the herein contined
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 his 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 his
death.
Signed: _____________
