Fillable North Dakota Living Will printable pdf download

North Dakota Living Will

N.D. Cent. Code, § 23-06.4-03

I declare on (month, day, year): ____________________________________

a. I have made the following decision concerning life-prolonging treatment (initial 1, 2, or 3):

(1) [_____] I direct that life-prolonging treatment be withheld or withdrawn and that I be permitted to die naturally if two

physicians certify that:

(a) I am in a terminal condition that is an incurable or irreversible condition which, without the administration of life-

prolonging treatment, will result in my imminent death;

(b) The application of life-prolonging treatment would serve only to artificially prolong the process of my dying; and

It is my intention that this declaration be honored by my family and physicians as the final expression of my legal right to

refuse medical or surgical treatment and that they accept the consequences of that refusal, which is death.

(2) [_____] I direct that life-prolonging treatment, which could extend my life, be used if two physicians certify that I am in a

terminal condition that is an incurable or irreversible condition which, without the administration of life-prolonging treatment, will

result in my imminent death. It is my intention that this declaration be honored by my family and physicians as the final expression of

my legal right to direct that medical or surgical treatment be provided.

(3) [_____] I make no statement concerning life-prolonging treatment.

b. I have made the following decision concerning the administration of nutrition when my death is imminent (initial only one

statement):

(1) [_____] I wish to receive nutrition.

(2) [_____] I wish to receive nutrition unless I cannot physically assimilate nutrition, nutrition would be physically harmful or

would cause unreasonable physical pain, or nutrition would only prolong the process of my dying.

(3) [_____] I do not wish to receive nutrition.

(4) [_____] I make no statement concerning the administration of nutrition.

c. I have made the following decision concerning the administration of hydration when my death is imminent (initial only one

statement):

(1) [_____] I wish to receive hydration.

(2) [_____] I wish to receive hydration unless I cannot physically assimilate hydration, hydration would be physically harmful

or would cause unreasonable physical pain, or hydration would only prolong the process of my dying.

(3) [_____] I do not wish to receive hydration.

(4) [_____] I make no statement concerning the administration of hydration.

d. Concerning the administration of nutrition and hydration, I understand that if I make no statement about nutrition or hydration,

my attending physician may withhold or withdraw nutrition or hydration if the physician determines that I cannot physically assimilate

nutrition or hydration or that nutrition or hydration would be physically harmful or would cause unreasonable physical pain.

e. If I have been diagnosed as pregnant and that diagnosis is known to my physician, this declaration is not effective during the

course of my pregnancy.

North Dakota Living Will