__________(1)_____________, of ___________(2)____________, being of sound mind,
do hereby willfully and voluntarily make known my desire that my life not be
prolonged under any of the following conditions, and do hereby further declare:
If I should, at any time, have an incurable condition caused by any disease or
illness, or by any accident or injury, and be determined by any two or more
physicians to be in a terminal condition whereby the use of "heroic
measures" or the application of life-sustaining procedures would only
serve to delay the moment of my death, and where my attending physician has
determined that my death is imminent whether or not such "heroic
measures" or life-sustaining measures are employed, I direct that such
measures and procedures be withheld or withdrawn and that I be permitted to die
In the event of my inability to give directions regarding the application of
life-sustaining procedures or the use of "heroic measures", it is my
intention that this directive shall be honored by my family
and physicians as my final expression of my right to refuse medical and
surgical treatment, and my acceptance of the consequences of such refusal.
am mentally, emotionally and legally competent to make this directive and I
fully understand its import.
reserve the right to revoke this directive at any time.
This directive shall remain in force until revoked.
WITNESS WHEREOF, I have hereto set my hand and seal this _(3)_ day of _______
Declaration of Witnesses
declarant is personally known to me and I believe him to be of sound mind and
emotionally and legally competent to make the herein contined
Directive to Physicians. I am not related to the declarant by blood or
marriage, nor would I be entitled to any portion of the declarant's estate upon
his decease, nor am I an attending physician of the declarant, nor an employee
of the attending physician, nor an employee of a health care facility in which
the declarant is a patient, nor a patient in a health care facility in which
the declarant is a patient, nor am I a person who has any claim against any
portion of the estate of the declarant upon his death.
information in this document is designed to provide an outline that you can
follow when formulating business or personal plans. Due to the variances of
many local, city, county and state laws, we recommend that you seek
professional legal counseling before entering into any contract or agreement.
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