Living Will Declaration Form - 2005 printable pdf download

PAGE 15

VOLUME XIII, ISSUE 3

IN GOOD FORM

Ed. Note: This form was a part of Act 447 (HB 675) of the '05 Regular Session of the Legislature. We

believe other forms in this issue do the same thing with better wording, but since it was part of the

Act, we include it here.

DECLARATION

Declaration made this _______ day of _______________________(month,year).

I, __________________________, being of sound mind, willfully (sic) and voluntarily make

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

below and do hereby declare:

If at any time I should have an incurable injury, disease or illness, or be in a continual pro-

found comatose state with no reasonable chance of recovery, certified to be a terminal and irre-

versible 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 procedure would

serve only to prolong artificially the dying process, I direct (initial one only)

That all life-sustaining procedures, including nutrition and hydration, be withheld or with-

drawn so that food and water will not be administered invasively.

That all life-sustaining procedures, except nutrition and hydration, be withheld or withdrawn

so that food and water can be administered invasively.

I further direct 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 are.

In the absence of my ability to give directions regarding the use of such life-sustaining pro-

cedures, it is my intention that this declaration shall be honored by my family and physicians(s) as

the final expression of my legal right to refuse medical or surgical treatment and accept the conse-

quences from such refusal.

I understand the full import o this declaration and I am emotionally and mentally competent

to make this declaration.

Signed_______________________________________________

City, Parish and State of Residence

The declarant has been personally known to me and I believe him or her to be of sound mind.

Witness_________________________________________

Living Will Declaration Form - 2005