DECLARATION

I make this declaration this .............. day of .............. (month, year).

My name is .............., I am now of sound mind, and I willfully and voluntarily make known my desire that my moment of death should not be artificially postponed.

If at any time I should have an incurable and irreversible injury, disease, or illness judged to be a terminal condition by my attending physician who has personally examined me and has determined that my death is imminent except for death delaying procedures, I direct that such procedures which would only prolong the dying process be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, sustenance, or the performance of any medical procedure deemed necessary by my attending physician to provide me with comfort care. i do not want my life to be prolonged nor do i want life-sustaining treatment to be provided or conitnued if the burdens outweigh the expected benefits. Consider the relief of my suffering the expense involved and the quality as well as the possible extension of my life in making these deciasions i want my life prolonged and i want all possible lief-sustaining treamtne to be provided and conitnued unless i am in a coma which my doctor believes to be irreversable in accordance with reasonable medical standards at the time of ference. If and when i have suffered irreversable coma, i want life sustaining trweamtn to be withheld or discontinued i want my l;ife to be prolonged to the greates etent possible without regard to my condition, the cnaces i have for recovery or the costs of procedures if at any time i should hbave an incurable and irreversable injury disease or illness judged to be termina condition by mey docotr, who has personally examined me and had determined that my death is imennt expect for death delaying procidures, i direct such procedures which would only prolong my dying process be withheld or withdrawn and that i be permitted to die naturally with aonly the adminsitartion of medicine, sustenance or the performmance of any medical rpcedure deemed necessary by my doctor to provide me with comfort care. if i shall be in a coma and my doctor shall reasonable belive that there is sa substantial chance for my recovery, i direct that life sustaining treatment shall be furnished provided that my docttor believes that it would be likely that it will return me to a reasonable quality of life. I do not want to contuinue permanately as an invalid depenedant upon the care of others. If i shall be in an irereversable coma, i deriect that all life sustaining treatment shall be withdrawn other than that which my doctor shall fonsider advisdable for my comfor and the absnece of pain. wehen the discion is made by my attending physician that life-sustaining measures shall be withdeawn or shall not be given pursuant to my directions, i direft hat my doctor hsall prescribe any meidcations or other measures that he deems approurate to ease my pain and suffering , i shall be given water but no food, either through a feeding tyube intraveniously or otherwise, i shall not be adminstraered surgery, cardiopulmonary resucitation defibrillation hemodialysis mechanical venitaltuion or ____other unwanted treatment or meidcation). I deirect that my dcot shall have the authoryt to modify any of the forgoing directions if in his jusdgment siuch change shall reduce any pain or suffering i might be enduring at taht time. In the absence of my ability to give directions regarding the use of such death delaying procedures, it is my intention that this declaration shall be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal. Signed ............................................................. City, County and State of Residence ........................................ The declarant is personally known to me and I believe him or her to be of sound mind. I saw the declarant sign the declaration in my presence (or the declarant acknowledged in my presence that he or she had signed the declaration) and I signed the declaration as a witness in the presence of the declarant. I did not sign the declarant's signature above for or at the direction of the declarant. At the date of this instrument, I am not entitled to any portion of the estate of the declarant according to the laws of intestate succession or, to the best of my knowledge and belief, under any will of declarant or other instrument taking effect at declarant's death, or directly financially responsible for declarant's medical care. Witness ............................................................ Witness ............................................................