Catholic Declaration On Life And Death (Page 2 of 3) in pdf

Catholic Declaration On Life And Death Page 2

The following gives guidance for carrying out my wishes at the end of life. If at any time I am

incapacitated and I have a terminal condition or I have an end-stage condition, and if my attending or

treating physician and another consulting physician have determined that there is no reasonable

medical probability of my recovery from such condition(s), my health care surrogate (designated

above, if any) will be authorized to make decisions for me in accordance with my wishes expressed in

this Declaration. If my surrogate cannot be contacted (or I have not named a surrogate), then I request

and direct that each of the following be considered in making a decision for me.

That:

1. I be provided care and comfort, and that my pain be relieved;

2. No inappropriate, excessively burdensome nor disproportionate means be used to prolong my

life. This can include medical or surgical procedures;

3. There should be a presumption in favor of providing nutrition and hydration to me, including

medically assisted nutrition and hydration, as long as this is of sufficient benefit to outweigh the

burdens involved to me;

4. Nothing be done with the intention of causing my death; and

5. Spiritual care be provided, including sacraments whenever possible.

Additional Instructions

Signatures Required

It is my intention that my surrogate, family and physicians honor this declaration as the expression of my

treatment wishes. I understand the full import of this declaration, and I am emotionally and mentally

competent to make this declaration.

DECLARANT

Date

Last 4 Social Security Number:________________

Two Witnesses:

The Health Care Surrogate cannot serve as a witness; at least one witness must not be a spouse or

blood relative of the person signing.

STATEMENT OF WITNESSES: I declare under penalty of perjury under the laws of California

(1) that the individual who signed or acknowledged this advance health care directive is

personally known to me, or that the individual’s identity was proven to me by convincing evidence

(2) that the individual signed or acknowledged this advance directive in my presence, 3) that the

individual appears to be of sound mind and under no duress, fraud, or undue influence, (4) that I am not a

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Catholic Declaration On Life And Death Page 2