I, __________(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:
1. 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measures and procedures be withheld or withdrawn and that I be permitted to die naturally.
2. 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.
3. If I have been diagnosed as pregnant and such diagnosis is known to my physicians,
this directive shall have no force or effect during the course of my pregnancy.
4. I am mentally, emotionally and legally competent to make this directive and I fully
understand its import.
5. I reserve the right to revoke this directive at any time.
6. This directive shall remain in force until revoked.
IN WITNESS WHEREOF, I have hereto set my hand and seal this _
(3)_ day of _______(4)_______, 19_(5)_.
Declaration of Witnesses
The declarant is personally known to me and I believe her to be of sound mind and
emotionally and legally competent to make the herein contained 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 her 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 her death.