This declaration is made on _________[date].
I, _________,willfully and voluntarily make known my desire that my dying not beartificially prolonged under the circumstances set forth below, and I dodeclare:
If at any time Ihave a terminal condition and if my attending or treating physician and anotherconsulting physician have determined that there is no medical probability of myrecovery from that condition, I direct that life-prolonging procedures bewithheld or withdrawn, when the application of the procedures would serve onlyto prolong, artificially, the process of dying, and that I be permitted to dienaturally with only the administration of medication or the performance of anymedical procedure deemed necessary to provide me with comfort or care or toalleviate pain.
It is my intentionthat this declaration be honored by my family and physician as the finalexpression of my legal right to refuse medical or surgical treatment and toaccept the consequences for that refusal.
Inthe event that I have been determined to be unable to provide express andinformed consent regarding the withholding, withdrawal, or continuation oflife-prolonging procedures, I wish to designate, as my surrogate to carry outthe provisions of this declaration:
I understand thefull import of this declaration, and I am emotionally and mentally competent tomake this declaration.
___________________________________ [Signature]
ATTESTATION CLAUSEOn _________[date],_________[name], known to us to be the person whose signature appears at theend of the above directive, declared to us, the undersigned, that the abovedirective, consisting of _________ pages, including the page on which we havesigned as witnesses, was _________[his or her] directive. _________[He or She]then signed the directive in our presence and, at _________[his or her]request, in _________[his or her] presence and in the presence of each other,we now sign our names as witnesses.
_________[Name]declarant has been personally known to us and we believe _________[him or her]to be of sound mind. We are not related to _________[name] by blood ormarriage, nor would we be entitled to any part of _________[name's] estate on_________[name's] death, nor are we the attending physicians of _________[name]or an employee of the attending physician or a health facility in which_________[name] is a patient, or a patient in the health care facility in which_________[name] is a patient, or any person who has a claim against any part ofthe estate of the _________[name] on _________[name's] death.
______________________________, residing at [Signature]
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______________________________, residing at [Signature]
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______________________________, residing at [Signature]
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