Declaration

Declaration made this _______ day of ________(month, year.) I, _____________ _________________________ willfully and voluntarily make known my desire and do hereby declare:

You must choose between the following two paragraphs. The one on the left designates a person to make a decision for you. In the one on the right, you make the decision. Cross through the paragraph you do NOT want.

If at any time I should have a terminal condition and my attending physician has determined that there can be no recovery from such condition, my death is imminent, and I am comatose, incompetent to otherwise mentally or physically incapable of communication, I designate ________________________
___________________________ to make a decision on my behalf as to whether life prolonging procedures shall be withheld or withdrawn. I wish to 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, care or to alleviate pain.

If at any time I should have a terminal condition and my attending physician has determined that there can be no recovery from such condition and my death is imminent, where the application of life-prolonging procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me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, care or to alleviate pain.

In the absence of my ability to give directions regarding the use of such life-prolonging procedures, it is my intention that this declaration shall be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences of such refusal. I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration.

(Signed)________________________________________________ The declarant is known to me, and I believe him or her to be of sound mind.

(Witness)________________________________________________ (Witness)________________________________________________