Form 120 - Living Will Declaration printable pdf download

LIVING WILL DECLARATION

K.S.A. 65-28, 101 et seq. as amended

I, _____________________________, being of sound mind, willfully and voluntarily making

known my desire that my dying shall not be artificially prolonged under the circumstances set forth

below, do hereby declare:

If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two physicians who

have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my

death will occur whether or not life-sustaining procedures are utilized and where the application of life-sustaining

procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn

and that I be permitted to die naturally with only the administration of medication or the performance of any medical

procedure deemed necessary to provide me with comfort care.

In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this

declaration shall be honored by my family and physician(s) as the final expression of my legal right to refuse medical or

surgical treatment and accept the consequences from such refusal.

I understand the full import of this declaration and I am emotionally and mentally competent to make this decision.

Declaration made this _______ (day) of _______________________________(month, year)

Signature:

X_____________________________________________________________________

Address:

(street)_________________________________________________________________

(city)___________________________ (state,zip)________________________________

This document must be witnessed by two individuals or acknowledged by a notary public.

Notary Public:

STATE OF____________ COUNTY OF ________________-____ SS:

This instrument was acknowledged before me this _______day of __________________(month, year)

Signature of Notary: _______________________________________

My appointment expires: ____________________________________

Witnesses:

The declarant has been personally known to me and I believe the declarant to be of sound mind. I did not sign the

declarant's signature above for or at the direction of the declarant. I am not related to the declarant by blood or marriage,

entitled to any portion of the estate of the declarant according to the laws of intestate succession or under any will of

declarant or codicil thereto, or directly responsible for declarant's medical care.

Name: _____________________________________ Name: ___________________________________

Address: ____________________________________ Address: __________________________________

City, State, Zip: ________________________________ City, State, Zip: _____________________________

Form # 120 Rev. 1/2002. Copy protected. Additional forms and information are available through Kansas Health Ethics, Inc.,

5900 East Central Ave., Suite 101, Wichita, KS 67208. Telephone (316) 684-1991.

Form 120 - Living Will Declaration