To my family, doctors, hospitals, and any
person concerned with my care:
I, ________________________ , being of sound mind willfully and voluntarily make
this declaration to be followed if I should
be in an incurable or irreversible mental or physical condition with no
reasonable expectation of recovery, I direct my attending physician to withhold
or withdraw treatment that merely prolongs my dying.
These directions express my legal right to refuse treatment. I expect the above mentioned parties to regard themselves as legally and morally bound to act in accordance with my wishes, free, thereby, of any legal liability for having followed my directions.
1. I direct my attending physician to withhold or withdraw life-sustaining treatment that serves only to prolong the process of my dying, if I should be in a incurable or irreversible mental or physical condition with no reasonable expectation of recovery.
2. I direct that treatment be limited to measures to keep me comfortable and pain free, including any pain that might occur by withholding or withdrawing life-sustaining treatment.
3. In addition, if I am in the condition described above, I feel strongly about not wanting the following forms of treatment:
a.
b.
c.
(you may list specific treatment you do
not want. For example, cardiac resuscitation, mechanical respiration, artificial
feeding, artificial fluids by tubes, etc)
Other Instruction:
4. Should I become unable to communicate my instructions as stated above, I designate the following person to act in my behalf:
Name:__________________________________________________________________________
Address: _______________________________________________________________________
If the person I have named above is unable to act on my behalf, I authorize the following person to do so:
Name:__________________________________________________________________________
Address: _______________________________________________________________________
This Living Will Declaration expresses my wishes, and the fact that I may have
executed a form specified by state law shall not be construed as limiting or
contradicting this Declaration, which is an expression of my common-law and
constitutional rights.
I make this declaration on this the ____ day of __________ , ______.
| Signed _______________________ Date _______________________ |
Witness
_______________________ Address _______________________ Witness _______________________ |
(Form provided by Arthritis Insight )