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DECLARATION AS TO MEDCAL OR SURGICAL TREATMENT
I _________________, being of sound mind and at least 18 years of age, direct that my life shall not be artificially prolonged
under the circumstances set forth below and hereby declare that:
1. If at any time my attending physician and one other physician certify in writing that:
a. I have an injury, disease or illness which is not curable or reversible and which, in their judgment is a terminal
condition; and
b. For a period of seven consecutive days or more, I have been unconscious, comatose or otherwise incompetent so as to
be unable to make or communicate responsible decisions concerning my person; then
I direct that in accordance with the laws of the State of ________________, life-sustaining procedures shall be withdrawn
and withheld pursuant to the terms of this declaration; it being understood that life-sustaining procedures shall not include
any medical procedure or intervention for nourishment considered necessary by the attending physician to provide comfort or
alleviate pain. However, I may specifically direct, in accordance with ________{name of state} law, that artificial nourishment
be withdrawn or withheld pursuant to the terms of this declaration.
2. In the event that the only procedure I am being provided is artificial nourishment, I direct that one of the following
actions be taken:
______ (a) Artificial nourishment shall not be continued when it is the only procedure being provided; or
______* (b) Artificial nourishment shall be continued for ______ days when it is the only procedure being provided;
or
______* (c) Artificial nourishment shall be continued whe it is the only procedure being provided.
3. I execute this declaration as my free and voluntary act this ___ day of_______, 20___.
By: ___________________________________
Declarant
The foregoing instrument was signed and declared by ______________ to be her/his declaration, in the presence of us, who,
in her/his presence, in the presence of each other, and at her/his request, have signed our names below as witnesses, and
we declare that, at the time of the execution of this instrument, the declarant, according to our best knowledge and belief,
was of sound mind and under no constraint or undue influence. We further declare that neither of us is: 1) a Physician; 2)
the declarant'Z physician or an employee of her/his physician; 3) an employee or a patient of the health care facility in
which the declarant is a patient; or 4) a beneficiary or creditor of the estate of the declarant.
Dated at _______________ [City], ________________[State], this ___ day of _____, 20___.
__________________________________
(signature of witness)
__________________________________
Address
___________________________________
(signature of witness)
___________________________________
Address
State of ___________ )
)
County of __________ )
Subscribed and sworn to or affirmed before me by _________________, the declarant and _________________ and ______________________,
witnesses, as the voluntary act and deed of the declarant, this _______________ day of ________, 20________.
My commission expires:____________________________
_________________________
Notary Public
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