Indiana Living Will Declaration

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Indiana Living Will Declaration
Declaration made this _____ day of ___________ (month, year). I, _____________,
being at least eighteen (18) years of age and of sound mind, willfully and voluntarily
make known my desires that my dying shall not be artificially prolonged under the
circumstances set forth below, and I declare:
If at any time my attending physician certifies in writing that: (1) I have an incurable
injury, disease, or illness; (2) my death will occur within a short time; and (3) the use of
life prolonging 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direct that such procedures be withheld or withdrawn, and that I be permitted to die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 performance or provision of any medical procedure or medication
necessary to provide me with comfort care or to alleviate pain, and, if I have so indicated
below, the provision of artificially supplied nutrition and hydration. (Indicate your choice
by initialing or making your mark before signing this declaration):
__________ I wish to receive artificially supplied nutrition and hydration, even if
the effort to sustain life is futile or excessively burdensome to me.
__________ I do not wish to receive artificially supplied nutrition and hydration, if
the effort to sustain life is futile or excessively burdensome to me.
__________ I intentionally make no decision concerning artificially supplied
nutrition and hydration, leaving the decision to my health care representative appointed
under IC 16-36-1-7 or my attorney in fact with health care powers under IC 30-5-5.
In the absence of my ability to give directions regarding the use of life prolonging
procedures, it is my intention that this declaration be honored by my family and physician
as the final expression of my legal right to refuse medical or surgical treatment and accept
the consequences of the refusal.
I understand the full import of this declaration.
Signed _________________________
_____________________________________________
City, County, and State of Residence
The declarant has been personally known to me, and I believe (him/her) 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 a parent, spouse, or child of the declarant. I am not entitled to any part of the
declarant's estate or directly financially responsible for the declarant's medical care. I am
competent and at least eighteen (18) years of age.
Witness _______________ Date __________
Witness _______________ Date __________

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