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[Coupled With Durable Power of Attorney]
Directive made [date]. I, [name], residing in [county, state], being of sound mind, willfully and voluntarily make known my desire that my life shall, not be artificially prolonged under the circumstances set forth below, do hereby declare:
01. Directed Treatment. If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two physicians, and where the application of life-sustaining procedures would serve only to artificially prolong the moment of my death and where my physician determines that my death is imminent whether or not life-sustaining procedures are utilized, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally.
01. Directive Not to Use or to Discontinue Life-Prolonging Medical Treatment When Recovery Is Unlikely. In the event I suffer from an injury, disease, illness, or other physical or mental condition that renders me unable to make medical decisions on my own behalf, that leaves me unable to communicate with others meaningfully, and from which there is no reasonable prospect of recovery to a cognitive and sentient life, I direct that no medical treatments or procedures (except as provided below) be utilized in my care or, if begun, that they be discontinued.
02. Definition of Medical Treatment. By "medical treatments or procedures," I mean interventions by medical doctors, nurses, paramedics, or any other health care provider (including a nursing home) in the care of my body and mind, including all medical and surgical procedures, mechanical or otherwise, treatments, therapies, including drugs and hormones, that may substitute for, replace, supplant, enhance, or assist any bodily function. This specifically includes maintenance of respiration, nutrition, and hydration by artificial means. With respect to all medical treatments or procedures, I include both existing technology and any methods or techniques that may be hereafter developed and perfected.
03. Provision for Pain Control. I ask that medical treatment to alleviate pain, to provide comfort, and to mitigate suffering be provided so that I may be as free of pain and suffering as possible.
04. Inability to Give Directions. In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this
Directive 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 from such refusal.
05. Determination of Prognosis. My Attorney-in-Fact acting pursuant to my duly executed Power of Attorney shall follow my directions as set out in this Health Care Declaration whenever my Attorney-in-Fact has ascertained by applying reasonable medical standards that my condition is as described in Paragraph 1, above. Absent the instructions of my Attorney-in-Fact, any other person shall comply with my directions upon certification by two physicians that my condition is as described in Paragraph 1, above.
06. Terminal Condition. I have been diagnosed and notified within the previous [number] days as having a terminal condition by [physician's name], MD, whose address is [address], and whose telephone number is [number]. I understand that if I have not filled in the physician's name and address, it shall be presumed that I did not have a terminal condition when I made out this Directive.
07. Term of Directive. This Directive shall have no force or effect [number] years from the date filled in above.
08. Acknowledgment of Effects of This Declaration. I make and execute this Declaration knowing that, if complied with, my death will occur sooner than it would were all available and appropriate medical treatments considered and used. I accept this as a necessary result of a decision to avoid dependence and pain. And I make the decision now, for myself, after careful consideration, to ensure that I will have the level of medical care that I want and to relieve others of the burden of decision.
09. Mental and Emotional Competence. I understand the full import of this Directive, and I am emotionally and mentally competent to make this Directive.
10. IN WITNESS WHEREOF, this Living Will has been signed on the date first above written.
[city, county, and state of residence]
This declarant has been personally known to me, and I believe him/her to be of sound mind.
[name of witness]
Residing at [address]
[name of second witness]
Residing at [address]
0. Pregnancy. If I have been diagnosed as pregnant and that diagnosis is known to my physician, this Directive shall have no force or effect during the course of my pregnancy.