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LIVING WILL DECLARATION
I, (NAME)
of (ADDRESS)
being of sound mind, willfully and voluntarily make this declaration to be
followed if I become incompetent or otherwise incapable of expressing my decision
concerning my medical treatment. This declaration reflects my firm and settled
commitment to refuse life-sustaining treatment under the circumstances indicated
below.
I direct my attending physician, or whomever may be involved in such a decision,
to withhold or withdraw life-sustaining treatment that serves only to prolong the
process of my dying, if I should be in a terminal condition, a persistent
vegetative state, irreversible coma or in a state of permanent unconsciousness.
Unless I indicate to the contrary in the paragraphs below, I direct that
treatment be limited to measures to keep me comfortable and to relieve pain,
including any pain that might occur by withholding or withdrawing life-sustaining
treatment.
In addition, if I am in the condition described above, I hereby make the
following advance directions about the following forms of treatment:
I DO/DO NOT want cardiac resuscitation or a cardiac pacemaker.
I DO/DO NOT want blood or blood products.
I DO/DO NOT want tube feeding or any other artificial or invasive form of nutrition
(food) or hydration (water).
I DO/DO NOT want mechanical respiration.
I DO/DO NOT want kidney dialysis.
I DO/DO NOT want antibiotics.
I DO/DO NOT want any form of surgery or invasive diagnostic tests.
I DO/DO NOT want receipt of an organ.
I realize that if I do not specifically indicate my preference regarding any of
the forms of treatment listed above, I may receive that form of treatment.
OTHER INSTRUCTIONS:
I DO/DO NOT want to designate another person as my surrogate to make medical
treatment decisions for me if I should become incompetent and in a terminal
condition or in a state of permanent unconsciousness.
Name of surrogate (if applicable):
The declarant or the person on behalf of and at the direction of the declarant
knowingly and voluntarily signed this writing by signature or mark in my
presence.
Declarant's signature
I made this declaration on the Declarant's address: X day of XX, 20XX.
Witness' signature Witness' signature
Witness' address
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