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Living Will Coupled With Durable Power Of Attorney
KNOW ALL MEN by these presents that I, [name], a resident of [county, state], hereby declare my will with respect to my medical care and treatment in the event I am unable for any reason to make known my will at the time medical decisions must be made.
1. 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.
2. 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.
3. 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.
4. 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.
5. 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.
This Section for Notary:
STATE OF -------)
) ss: [date]
COUNTY OF ------)
On [Date] before me, [Name of Notary], notary, personally appeared [Name of Person(s) Involved], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
Witness my hand and official seal.
[Name of Notary Public]
My commission expires: [date]