Fillable Statutory Advance Directive (Page 3 of 8) in pdf

Statutory Advance Directive Page 3

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Declaration made this _________ day of ___________________________ 20_______.

2. I, ______________________________________________________________, being at least

18 years of age and of sound mind, willfully and voluntarily make known my desires that

my dying shall not be artificially prolonged under the circumstances set forth below:

I declare that, if at any time my attending physician certifies in writing that: a) I

have an incurable injury, disease, or illness; b) my death will occur within a short

time; and, c) the use of life prolonging procedures would only artificially prolong

the dying process – then I direct that such procedures be withheld or withdrawn,

and that I be permitted to die naturally with only the performance or provision of

any medical procedure or medication necessary to provide me with comfort care

or to alleviate pain.

Regarding Tube Feeding and Hydration:

4. My wishes regarding the use of artificial nutrition and hydration are recorded here.

(Indicate your choice, below, by initialing before signing this declaration):

_____ I wish to receive artificially supplied nutrition and hydration, even if the effort to

sustain life is futile or excessively burdensome to me.

OR,

_____ I do not wish to receive artificially supplied nutrition and hydration, if the effort to

sustain life is futile or excessively burdensome to me.

OR,

_____ I intentionally make no decision concerning artificially supplied nutrition and

hydration, leaving the decision to any health care representative I may have

appointed under IC §16-36-1-7 or to my attorney-in-fact with health care powers

under IC §30-5-5.

Additional Instructions:

5. I also wish to add the following additional instructions: ____________________________

_____________________________________________________________________

Declaration Intent:

6. In the absence of my ability to give directions regarding the use of life prolonging procedures,

it is my intention that this declaration be honored by my family and physician as the final

expression of my legal right to refuse medical or surgical treatment and I accept the

consequences of the refusal. I understand the full import of this declaration.

Statutory Advance Directive Page 3

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