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Election of Treatment(s)
After you have completed this form and printed it out, you will be
allowed you to check off treatments you want and don't want.
Among those are matters which relate to treatment while you are
permanently unconscious and the condition is irreversible. You
will be given the option of receiving artificial nutrition and
hydration and other treatment.
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Operative Date
Your living will becomes operative when a copy is provided to
your attending physician; and you are determined by
your attending physician to be incompetent and in a terminal condition or
in a state of permanent unconsciousness.
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Anatomical Gifts
You will be able to make
an anatomical gift of your body, parts of your body or none at all.
If you elect to donate organs and/or tissues for transplantation, you
may be maintained on artificial support systems only for the period of
time required to maintain the viability of and to remove such organs
and/or tissues.
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Revocation
You may revoke your
declaration at any time and in any manner by which you are able to
communicate your intent to revoke, without regard to your mental or
physical condition. Such revocation shall become effective only upon
communication to your attending physician by you or by an individual
acting on your behalf.
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Ancillary Effect of
Executing Living Will
The execution and
consummation of this declaration shall not constitute a suicide for any
purpose nor may any person be required to sign a declaration as a
condition for becoming insured under any insurance contract or for
receiving any medical treatment.
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 Executing and Delivering Your Living Will
After you have completed
and printed out your living will, you must gather two witnesses for signing
in front of a notary public. The original or a copy should be
submitted to your physician for entry in your medical records. If you
revoke your living will, you should also submit the original to your
physician to be placed in your medical records as well.
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If you should have an
incurable or irreversible condition that will
cause your death within a relatively short time, you may declare that your
life not be prolonged by administration of life-sustaining procedures.
If your condition is terminal and you are unable to participate in
decisions regarding your medical treatment, you may direct your attending
physician to withhold or withdraw procedures that merely prolong the dying
process and are not necessary to your comfort or to alleviate pain.
