(b) It shall be the responsibility of declarant to provide for notification to the declarant's attending physician of the existence of the declaration. An attending physician who is so notified shall make the declaration, or a copy of the declaration, a part of the declarant's medical records.
(c) The declaration shall be substantially in the following form, but
in addition may include other specific directions. Should any of the other
specific directions be held to be invalid, such invalidity shall not affect
other directions of the declaration which can be given effect without the
invalid direction, and to this end the directions in the declaration are
severable.
Declaration made this ___________ day of ______ (month, year). I,
_____________, 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, do hereby declare:
If at any time I should have an incurable injury, disease, or illness certified
to be a terminal condition by two physicians who have personally examined
me, one of whom shall be my attending physician, and the physicians have
determined that my death will occur whether or not life-sustaining procedures
are utilized and where the application of life-sustaining 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procedures be withheld or withdrawn, and that I be permitted to die naturally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.
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
from such refusal.
I understand the full import of this declaration and I am emotionally and
mentally competent to make this declaration.
Signed ____________________________________
City, County and State
of Residence ______________________________
The declarant has been personally known to me and I believe
the declarant to be of sound mind.
I did not sign the declarant's signature above for or at the direction
of the declarant. I am not related to the declarant by blood or marriage,
entitled to any portion of the estate of the declarant according to the
laws of intestate succession or under any will of declarant or codicil thereto,
or directly financially responsible for declarant's medical care.
Witness ___________________________________________
Witness ___________________________________________
STATE OF ____________________)
______________________________ ss.
COUNTY OF ____________________)
This instrument was acknowledged before me on ________ (date) by
______________________ (name of person)
____________________________________________________
(Seal, if any)
My appointment expires: ________________________
Copies
History: L. 1979, ch. 199, § 3;
L. 1994, ch. 224, § 2; July 1.