Living Will Declaration (Alternate Form)

Directive made this _____ day of _____________________, 20______.

I, _______________________________________, 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:

GENERAL PRESUMPTION FOR LIFE

I direct my health care provider(s) and health care agent to make health care decisions consistent with my general desire for the use of medical treatment that would preserve my life, as well as for the use of medical treatment that can cure, improve, or reduce or prevent deterioration in, any physical or mental condition.

Food and water are not medical treatment, but basic necessities. I direct my health care  provider(s) and health care agent to provide me with food and fluids orally, intravenously, by tube, or by other means to the full extent necessary both to preserve my life and to assure me the optimal health possible.

I direct that medication to alleviate my pain be provided, as long as the medication is not used in order to cause my death.

I direct that the following be provided: the administration of medication, cardiopulmonary resuscitation (CPR), and the performance of all other medical procedures, techniques, and technologies. including surgery, - all to the full extent necessary to correct, reverse, or alleviate life-threatening or health-impairing conditions, or complications arising from those conditions.

I also direct that I be provided basic nursing care and procedures to provide comfort care.

I reject, however, any treatments that use an unborn or newborn child, or any tissue or organ of an unborn or newborn child, who has been subject to an induced abortion. This rejection does not apply to the use of tissues or organs obtained in the course of the removal of an ectopic pregnancy.

I also reject any treatments that use an organ or tissue of another person obtained in a manner that causes, contributes to, or hastens that person's death.

The instructions in this document are intended to be followed even if suicide is alleged to be attempted at some point after it is signed.

I request and direct that medical treatment and care be provided to me to preserve my life without
discrimination based on my age or physical or mental disability or the "quality" of my life. I reject any action or omission that is intended to cause or hasten my death.

I direct my health care provider(s) and health care agent to follow the above policy, even if I am judged to be incompetent.

During the time I am incompetent, my agent, as named below, is authorized to make medical decisions on my behalf, consistent with the above policy, after consultation with my health care provider(s), utilizing the most current diagnoses and/or prognosis of my medical condition, in the following situations with the written special conditions.

WHEN MY DEATH IS IMMINENT

A. If I have an incurable terminal illness or injury, and I will die imminently -- meaning that a reasonably prudent physician, knowledgeable about the case and the treatment possibilities with respect to the medical conditions involved, would judge that I will live only a week or less even if lifesaving treatment or care is provided to me -- the following may be withheld or withdrawn:

• Any treatment that will, itself, cause me severe, intractable, and long-lasting pain but will not cure me.
• (Other)________________________________________________________________

WHEN I AM TERMINALLY ILL

B. Final Stage of Terminal Condition. If I have an incurable terminal illness or injury and even though death is not imminent I am in the final stage of that terminal condition - meaning that a reasonably prudent physician, knowledgeable about the case and the treatment possibilities with respect to the medical conditions involved, would judge that I will live only three months or less, even if lifesaving treatment or care is provided to me - the following may be withheld or withdrawn:

• Medications intended to relieve pain but which seriously threaten to shorten my life.
• (Other)________________________________________________________________

C. Other Special Conditions:

• (Other)________________________________________________________________

IF I AM PREGNANT

D. Special Instructions for Pregnancy. If I am pregnant, I direct my health care provider(s) and health care agent to use all lifesaving procedures for myself with none of the above special conditions applying if there is a chance that prolonging my life might allow my child to be born alive. I also direct that lifesaving procedures be used even if I am legally determined to be brain dead if there is a chance that doing so might allow my child to be born alive. Except as I specify by writing my signature in the box below, no one is authorized to consent to any procedure for me that would result in the death of my unborn child.

If I am pregnant, and I am not in the final stage of a terminal condition as defined above. medical procedures required to prevent my death are authorized even if they may result in the death of my unborn child provided every possible effort is made to preserve both my life and the life of my unborn child.

This directive shall have no force or effect five years from the date filled in above.

I understand the full import of this directive and I am emotionally and mentally competent to make this directive in the City of __________________, County of __________________, State of __________________.

Witnesses

The declarant has been personally known to me and I believe his/her to be of sound mind.  I did not sign the declarant's signature above for or at the direction of the declarant.  I am at least 18 years of age and am not related to the declarant by blood or marriage, nor entitled to any portion of the estate of the declarant according to the laws of intestate succession of the State of ___________________ (state) or under any will of the declarant or codicil thereto as of the date of declarant's signature. Neither am I directly financially responsible for declarant's medical care. I am not the declarant's attending physician, an employee of the attending physician, or an employee of the health or care facility in which the declarant is a patient.

Witness #1:


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Witness #1's Signature

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Witness #1's Printed Name

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Witness #1's Address, Line 1

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Witness #1's Address, Line 2 (City, State, Zip)


Witness #2:

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Witness #2's Signature

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Witness #2's Printed Name

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Witness #2's Address, Line 1

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Witness #2's Address, Line 2 (City, State, Zip)

 
Subscribed and acknowledged, before me by _____________________________________________, and subscribed and sworn to before the witnesses, on the _______ day of __________________, 20_____.

(SEAL)

_______________________________________________
NOTARY PUBLIC

State of ___________________

My Commission Expires: ____________________________


Copies of this instrument have been given to:

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