I, the undersigned, being of sound mind, willfully and voluntarily make known my
desire that my dying shall not be artificially prolonged under the circumstances set forth below,
and do hereby declare:
If at any time I should have an incurable injury,
disease or illness, or be in a continual
profound comatose state with no reasonable chance of recovery, certified to be a terminal and
irreversible condition by two physicians who have personally examined me, one of whom shall
be my attending physician, and the physicians have determined within reasonable medical
judgment that the application of life-sustaining procedures would serve only to prolong
artificially the dying process, I direct that such procedures (including the invasive
administration of nutrition and hydration) be withheld or withdrawn and that I be permitted to
die naturally with only the administration of medication or the performance of any medical
procedures deemed necessary to provide me with comfort care.
In the absence of my ability to give directions regarding the use of such life sustaining
procedures, it is my intention that this declaration shall be honored by my family and
physician(s) 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 decision and I am emotionally and mentally
competent to make this Declaration. I further understand that I may revoke this Declaration at
any time by destroying all copies, by a written revocation that is dated and signed by me, or by
communicating my intent to revoke directly to my attending physician. Any revocation shall be
effective when made known to my attending physician.
Witnesses:
| _________________________ | _________________________ |
| _________________________ |
Thus done and signed on this ____ day of ___________ 20___ before the attesting competent witnesses who believe Declarant to be of sound mind, the witnesses having stated that they are not related to Declarant by blood or marriage and that they are not entitled to any portion of Declarant’s estate.