Living Will Declaration

**********THIS DOCUMENT IS ONLY A SAMPLE**********

IT MAY NOT CONFORM TO THE LAWS IN YOUR STATE

DISCUSS THIS DOCUMENT WITH YOUR PHYSICIAN(S), FAMILY MEMBERS, FRIENDS AND CLERGY AND PROVIDE THEM WITH A SIGNED COPY OR A PHOTOCOPY.

 
I, ____________________________, being of sound mind, willfully and 
voluntarily make known my desire that my dying shall not be 
artificially prolonged under the circumstances set forth below, 
subject to later revocation, and do hereby declare: 

If at any time I should have an incurable injury, disease, or illness 
certified to be a terminal condition by two physicians who have 
personally examined me, one of whom shall be my attending physician, 
and the physicians have determined that my death will occur whether 
or not life-sustaining procedures are utilized, and where the 
application of life-sustaining procedures would serve only to 
artificially prolong the dying process, and I am unable to 
participate in decisions regarding my medical treatment, I direct 
that such procedures be withheld or withdrawn, and that I be 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.  

In the absence of my ability to give directions regarding the use of 
such life-sustaining procedures, it is my intention that this 
declaration shall be honored by my family and physician(s) as the 
final expression of my legal right to refuse medical or surgical 
treatment and accept the consequences of such refusal.  

I understand the full import of this declaration, and I am 
emotionally and mentally capable to make this declaration.  

This declaration is made this _____ day of __________, 200___.  

My additional instructions, if any, are listed on the reverse side.  


                ______________________________________________ 
                Declarant 


The declarant has been personally known to me, and I believe the 
declarant to be of sound mind and 18 years or older.  The declarant 
voluntarily signed this document in my presence.  I did not sign the 
declarant's signature above for or at the direction of the declarant.  
I am 18 years or older and not related to the declarant by blood or 
marriage, am not entitled to any portion of the estate of the 
declarant either as a legal heir or under any will of declarant or 
any addition thereto, and am not directly financially responsible for 
declarant's medical care.  


                ______________________________________________ 
                Witness 

                ______________________________________________ 
                Address 

                ______________________________________________ 
                Witness 

                ______________________________________________ 
                Address 


SEE "OPTIONAL ADDITIONAL INSTRUCTIONS" BELOW 

This declaration and the "Optional Additional Instructions" may be 
revoked or changed by the declarant at any time.  


                   OPTIONAL ADDITIONAL INSTRUCTIONS 

If there is a statement below with which you do not agree, draw a 
line through it and add your initials.  


The following (or photocopy thereof) is a statement of my treatment 
wishes if I lack the capacity to make or communicate decisions 
regarding my medical treatment and there is no reasonable expectation 
that I will regain a meaningful quality of life.  

* I direct all life sustaining procedures be withheld or withdrawn if 
  I have: 
        * a terminal condition, or 
        * a condition, disease or injury without hope of significant 
          recovery, or 
        * extreme mental deterioration, or 
        * other ___________________________________________________ 

* Life-sustaining procedures I choose to have withheld or withdrawn 
  include: 
        * surgery 
        * heart-lung resuscitation (CPR) 
        * antibiotics 
        * mechanical ventilator (respirator) 
        * tube feeding (food and water delivered through a tube in 
          the vein, nose, or stomach) 
        * other ____________________________________________________ 

* If my physician believes that a certain life sustaining procedure 
or other medical treatment may provide me with comfort, relieve pain 
or lead to a significant recovery, I direct my physician to try the 
treatment for a reasonable period of time.  If it does not improve my 
condition, provide comfort or relieve pain, I direct the treatment be 
withdrawn even if so doing shortens my life.  

* I direct I be given medical treatment to relieve pain or to provide 
comfort, even if such treatment might shorten my life, suppress my 
appetite or my breathing, or be habit-forming.  

* A meaningful quality of life means to me that: (This does not need 
to be filled in for the instructions to be valid.) 

____________________________________________________________________ 

____________________________________________________________________ 

____________________________________________________________________ 

____________________________________________________________________ 

* I prefer to live out my last days at home rather than in a hospital 
or a nursing home if it is not a burden to my family.  

* If any of my tissues or organs would be of value as transplants to 
help other people, I freely give my permission for such donation.  

* I make other instructions as follows: 
____________________________________________________________________ 

____________________________________________________________________ 

* I have discussed my wishes with the following person(s) and 
authorize my physician to discuss my treatment and this document with 
them: 


_____________________________________________________________________ 
name                       address                         telephone 


_____________________________________________________________________ 
name                       address                         telephone 

* I have read these instructions and have given them careful 
consideration, and as I have indicated they are in accordance with my 
wishes.  


Date:_____________________         Signed: ________________________ 
                                               Declarant