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The online source for Wills,
Trusts, Power of Attorneys, and Living Wills Sample Declaration Concerning Life Sustaining Procedures 2. Declaration Concerning Life Sustaining Procedures: This document expresses that it is your desire that you do not care to have extraordinary efforts expended to keep you alive. This document should be given to your physician, hospital, and or care facility. This is a document of last resort. Tom’s health is fading fast and he is concerned that something is going to happen such as a stroke. While Tom would like to live as long as possible, he doesn’t want to live on a machine. This document lets the doctor know that, if its necessary for machines to keep Tom alive, they should just let nature takes it course. The document does allow for medication for comfort and to alleviate pain.
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DECLARATION
RELATING TO USE OF LIFE-SUSTAINING PROCEDURES DECLARATION If I should have an incurable or irreversible condition that will result either in death within a relatively short period of time or a state of permanent unconsciousness from which, to a reasonable degree of medical certainty, there can be no recovery, it is my desire that my life not be prolonged by the administration of life-sustaining procedures. If I am unable to participate in my health care decisions, I direct my attending physicians to withhold or withdraw life-sustaining procedures that merely prolong the dying process and are not necessary to my comfort or freedom from pain. I do, however ask that medication be mercifully administered to me to alleviate pain and suffering even though this may hasten the moment of death. Just because this is a short statement, don't think that this is a easy document to interpret. Some state will allow family members to override your desires, some will enforce this document conclusively. the important thing to remember is that this document expresses your wishes and desires and hopefully the family will consent at the appropriate time.
If I have executed a valid form of bequeath of any organs for transplant or research purposes, I do authorize that I be kept alive by artificial means for a time sufficient to enable the medical personnel to accomplish the withdrawal of the organs.
Signed this _________ day of _____________________, 2002. ___________________________________ Tom Sample 1500 Grand Avenue Ourtown, Anystate 95959 By signing this form I declare that I signed this form in the presence of the other witness and the Declarant and I witnessed the signing by the Declarant or by another person acting on behalf of and at the Declarant’s direction.
State Of Anystate § County of Big County On this _____ day of _________, A.D. 2002, before me the undersigned, a Notary Public in and for the State of Anystate, personally appeared Tom Sample and witnesses to me known to be the persons named in and who executed the foregoing instrument as Declarant and witnesses, and acknowledged that he or she and they executed the same as his or her and their voluntary act and deed. ___________________________________ Notary Public in and for the State of Anystate 1) This Declaration will be given effect only when the Declarant’s condition is determined to be terminal or Declarant is in a state of permanent unconsciousness and the Declarant is not able to make treatment decisions. 2) “Life-sustaining procedure” does not include the provision of nutrition or hydration except when required to be provided parenterally or through intubation or the administration of medication or performance of any medical procedure deemed necessary to provide comfort care or to alleviate pain. If you do not wish to have nutrition or hydration withdrawn under any circumstances, please consult an attorney for appropriate modification of this Declaration. 3) It is the responsibility of the Declarant to provide the Declarant’s attending physician or health care provider with this Declaration. 4) This Declaration may be revoked in any manner by which the Declarant is able to communicate the Declarant’s intent to revoke, without regard to mental or physical condition. A revocation is only effective as to the attending physician upon communication to such physician by the Declarant, or by another to whom the revocation was communicated by the Declarant. 5) No witness shall be an individual who is a relative of the Declarant by blood, marriage or adoption within the third degree of consanguinity. The following individuals shall not witness for a Declaration: a. A health care provider attending the Declarant on the date of execution. b. An employee of a health care provider attending the Declarant on the date of execution. c. An individual who is less than eighteen years of age.
Admonishment: It’s not our intent to give you legal advice. If you have any questions concerning the effect of any of these documents we remind you that you should contact an attorney in your state competent to advise you in this area of the law.
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