Living Will

Declaration made this_____________________ day of_______________________ I,_________________________________, willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do hereby declare:

If at any time I have a terminal condition and if my attending or treating physician and another consulting physi­cian have determined that there is no medical probability of my recovery from such condition, I direct that life­prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort or to alleviate pain.

It is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences for such refusal.

In the event that I have been determined to be unable to provide express and informed consent regarding the withholding, withdrawal or continuation of life-prolonging procedures, I wish to designate as my surrogate to carry out the provisions of this declaration:

Name__________________________________________________________________

Address_______________________________________ City______________________

State/Zip______________________________________ Phone____________________

I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration.

NUTRITION AND HYDRATION

____ I do ____ I do not desire that nutrition and hydration (food and water) be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying.

Additional instructions (optional)________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Signed___________________________________________________________________________

Witness Signature___________________________________________________________________

Name____________________________________________________________________________

Address____________________________________________ City___________________________

State/Zip____________________________________________ Phone_________________________

Witness Signature___________________________________________________________________

Name____________________________________________________________________________

Address____________________________________________ City___________________________

State/Zip______________________________________________ Phone_______________________

 This form courtesy of Kolodinsky, Seitz, Tresher and Brown.