Statutory Living Will Declaration Form - Kansas Page 2
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1
2OPTIONAL ADDITIONAL INSTRUCTIONS
In addition to the above and foregoing, all persons involved in decisions regarding my medical treatment shall
consider the following as clear and convincing evidence of my treatment wishes in the event I lack the capacity to make or
communicate decisions regarding my health care treatment and there is no realistic hope that I will regain such capacity:
If there is no reasonable hope that I will regain a meaningful quality of life and I have:
• a terminal condition;
• a condition, disease, or injury without reasonable expectation of significant recovery;
• substantial brain damage or brain disease, or extreme mental deterioration including dementia; or
• other ____________________________________________________________________________, then I direct that
life-saving or life-prolonging measures or procedures be administered or withheld/withdrawn in accordance with my
instructions marked below:
When any of the conditions described in the preceding paragraph exist, I request that I be provided all of the
following measures or interventions EXCEPT those that I have marked “No.”
Yes
No
SURGERY
Yes
No
DIALYSIS
Yes
No
HEART-LUNG RESUSCITATION (CPR)
Yes
No
ANTIBIOTICS
Yes
No
MECHANICAL VENTILATOR
Yes
No
TUBE FEEDING
(respirator requiring intubation)
(food and water delivered through tube
in the veins, nose, or stomach)
Yes
No
OTHER _______________________________
Yes
No
OTHER
If my physician believes that any life-saving or life-prolonging measure or intervention may lead to a
Yes
No
significant recovery (even those marked “No” above), I direct my physician to try the treatment for a
reasonable period of time. If it does not significantly improve my condition, I direct the treatment be
withdrawn, even if so doing shortens my life.
I direct that in all circumstances, I be given health care treatment to relieve pain or provide comfort, even if
Yes
No
such treatment might shorten my life, suppress my appetite or my breathing, or be habit-forming.
I consider a “meaningful quality of life” to include the following, which shall be taken into consideration by any
caregivers and/or surrogate decision makers in determining my course of medical treatment: _______________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
I make other instructions as follows: _____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Signature of Declarant _________________________________________________________________
(May be signed by another person in the declarant’s presence and by the declarant’s expressed direction.)
(1)
Witness __________________________________
Witness __________________________________
Address __________________________________
Address __________________________________
OR
(2)
STATE OF KANSAS
)
) ss:
COUNTY OF ____________________ )
This instrument was acknowledged before me on this _____ day of ___________________, 20___.
Signature of Notary Public
_____________________________________
My appointment expires:
_____________________________________
00003720S
Page 2 of 2
4/11
LW
Discuss this document with your physician(s), family members, designated agent(s), and clergy, and provide them with a signed copy or photocopy.
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