I, _____________________________________, born ________________________, Social Security number ___________________, being of sound mind, willfully and voluntarily make this Declaration to be followed if I become incompetent.  This Declaration reflects my firm and settled commitment to refuse life-sustaining treatment under the circumstances indicated below.

I direct my attending physician to withhold or withdraw the following life-sustaining treatment:

_____________________________________________________________

 _____________________________________________________________

 that serves only to prolong the process of my dying, if I should be in a terminal condition or in a state of permanent unconsciousness.

 I direct the treatment be limited to measures to keep me comfortable and 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 feel especially strong about the following forms of treatment:

 
I do (  ) do not (  ) want cardiac resuscitation.

I do (  ) do not (  ) want mechanical respiration.

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 blood or blood products

I do (  ) do not (  ) want any form of surgery or invasive diagnostic tests.

I do (  ) do not (  ) want kidney dialysis.

I do (  ) do not (  ) want antibiotics.

 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 be incompetent and in a terminal condition or in a state of permanent unconsciousness.

 
Name and Address of surrogate (if applicable):

_____________________________________

_____________________________________

_____________________________________

 

Name and address of substitute surrogate (if surrogate designated above is unable to serve):

_____________________________________

_____________________________________

_____________________________________

 
I made this declaration on the __________ day of ____________________________(month, year)

 

Declarant's Signature: _____________________________________________________________

 Declarant's Address: _____________________________________________________________

                                 _____________________________________________________________

 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.

 Signature of Witness: _____________________________________________________________

 Address: ________________________________________

                ________________________________________

 

Signature of Witness: _________________________________________

Address: ________________________________________

             ________________________________________