Missouri Living Will
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Missouri Living Will
9 CSR 10-5.180
DECLARATION
I have the primary right to make my own decisions concerning treatment that might unduly prolong the dying process. By
this declaration I express to my physician, family and friends my intent. If I should have a terminal condition it is my desire that my
dying not be prolonged by administration of death-prolonging procedures. If my condition is terminal and I am unable to participate
in decisions regarding my medical treatment, I direct my attending physician to withhold or withdraw medical procedures that merely
prolong the dying process and are not necessary to my comfort or to alleviate pain. It is not my intent to authorize affirmative or
deliberate acts or omissions to shorten my life rather only to permit the natural process of dying.
Signed this _____ day of ______________, 20_____.
________________________________
________________________________
Printed Name of Declarant
Signature of Declarant
Address:
____________________________________________
____________________________________________
WITNESSETH
The declarant is known to me, is eighteen years of age or older, of sound mind and voluntarily signed this document in my
presence.
Witness #1:
Witness #2:
________________________________
________________________________
Signature
Signature
________________________________
________________________________
Printed Name
Printed Name
________________________________
________________________________
Address, Line 1
Address, Line 1
________________________________
________________________________
Address, Line 2
Address, Line 2
REVOCATION PROVISION
I hereby revoke the above declaration.
________________________________
________________________________
Printed Name of Declarant
Signature of Declarant
Date: ________________
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