Missouri Living Will

MISSOURI LIVING WILL

DECLARATION

I have the primary right to make my own decisions concerning treatment that might unduly prolong the dying process. By this declaration I express to my physician, family and friends my intent. If I should have a terminal condition it is my desire that my dying not be prolonged by administration of death-prolonging procedures. If my condition is terminal and I am unable to participate in decisions regarding my medical treatment, I direct my attending physician to withhold or withdraw medical procedures that merely prolong the dying process and are not necessary to my comfort or to alleviate pain. It is not my intent to authorize affirmative or deliberate acts or omissions to shorten my life rather only to permit the natural process of dying.

Signed this _____ day of ______________, 20_____.

________________________________            ________________________________

Printed Name of Declarant                              Signature of Declarant

Address:  _________________________________

_________________________________

WITNESSETH

The declarant is known to me, is eighteen years of age or older, of sound mind and voluntarily signed this document in my presence.

Witness #1:                                                     Witness #2:

________________________________         ________________________________
Signature                                                         Signature

________________________________         ________________________________
Printed Name                                                   Printed Name

________________________________         ________________________________
Address, Line 1                                                Address, Line 1

 

________________________________         ________________________________
Address, Line 2                                                Address, Line 2

REVOCATION PROVISION

I hereby revoke the above declaration.

________________________________         ________________________________

Printed Name of Declarant                               Signature of Declarant

Date: ________________