North Carolina Declaration of a Desire for a Natural Death

North Carolina Declaration of a Desire for a Natural Death

I, _________, being of sound mind, desire that, as specified below, my life not be prolonged by extraordinary means or by artificial nutrition or hydration if my condition is determined to be terminal and incurable or if I am diagnosed as being in a persistent vegetative state. I am aware and understand that this writing authorizes a physician to withhold or discontinue extraordinary means or artificial nutrition or hydration, in accordance with my specifications set forth below:

(Initial any of the following, as desired):

_________ If my condition is determined to be terminal and incurable, I authorize the following:

_________ My physician may withhold or discontinue extraordinary means only.

_________ In addition to withholding or discontinuing extraordinary means if such means are necessary, my physician may withhold or discontinue either artificial nutrition or hydration, or both.

_________ If my physician determines that I am in a persistent vegetative state, I authorize the following:

_________ My physician may withhold or discontinue extraordinary means only.

_________ In addition to withholding or discontinuing extraordinary means if such means are necessary, my physician may withhold or discontinue either artificial nutrition or hydration, or both.

This the _________ day of _________

Signature _________

I hereby state that the declarant, _________, being of sound mind signed the above declaration in my presence and that I am not related to the declarant by blood or marriage and that I do not know or have a reasonable expectation that I would be entitled to any portion of the estate of the declarant under any existing will or codicil of the declarant or as an heir under the Interstate Succession Act if the declarant died on this date without a will. I also state that I am not the declarant's attending physician or an employee of the declarant's attending physician, or an employee of a health facility in which the declarant is a patient or an employee of a nursing home or any group-care home where the declarant resides. I further state that I do not now have any claim against the declarant.

Witness _________

Witness _________

The clerk or the assistant clerk, or a notary public may, upon proper proof, certify the declaration as follows:

Certificate

I, _________, Clerk (Assistant Clerk) of Superior Court or Notary Public (circle one as appropriate) for _________ County hereby certify that _________, the declarant, appeared before me and swore to me and to the witnesses in my presence that this instrument is his Declaration Of A Desire For A Natural Death, and that he had willingly and voluntarily made and executed it as his free act and deed for the purposes expressed in it.

I further certify that _________ and _________, witnesses, appeared before me and swore that they witnessed _________, declarant, sign the attached declaration, believing him to be of sound mind; and also swore that at the time they witnessed the declaration (i) they were not related within the third degree to the declarant or to the declarant's spouse, and (ii) they did not know or have a reasonable expectation that they would be entitled to any portion of the estate of the declarant upon the declarant's death under any will of the declarant or codicil thereto then existing or under the Intestate Succession Act as it provides at that time, and (iii) they were not a physician attending the declarant or an employee of an attending physician or an employee of a health facility in which the declarant was a patient or an employee of a nursing home or any group-care home in which the declarant resided, and (iv) they did not have a claim against the declarant. I further certify that I am satisfied as to the genuineness and due execution of the declaration.

This the _________ day of _________, _________

Clerk (Assistant Clerk) of Superior Court or

Notary Public (circle one as appropriate) for the

County of _________