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CONDITIONS
UNDER WHICH YOU MAY EXECUTE A LIVING WILL
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 If
at any time you should have an incurable and irreversible injury, disease,
or illness certified in writing to be a terminal condition by your
attending physician and one other qualified physician and for a period of
seven consecutive days or more you have been unconscious, comatose, or
otherwise incompetent so as to be unable to make or communicate
responsible decisions concerning your person, you may direct that such
procedures which would only prolong the dying process be withheld or
withdrawn, and that you be permitted to die naturally with only the
administration of medication, sustenance, or the performance of any
medical procedure deemed necessary by your attending physician to provide
you with comfort care.
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ADDITIONAL INFORMATION ABOUT THIS LIVING WILL |
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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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Duty of Attending
Physician(s)
When your living will becomes
operative, your physician and other health care providers shall act in
accordance with its provisions. If your attending physician or other
health care provider cannot in good conscience comply with the provisions
of your living will or if the policies of the health care provider
preclude compliance, your attending physician or health care provider
shall so inform you, or, if you are incompetent, shall so inform your
agent, or, if you have not designated a health care proxy, shall so inform
your family, guardian or other representative. Your physician and
health care provider shall make every reasonable effort to assist in the
your transfer to another physician or health care provider who will comply
with your living will.
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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.
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Revocation
Your living will may be
revoked at any time and in any manner by you without regard to your mental
or physical condition. A revocation is effective upon communication
to your attending physician or other health care provider by you or a
witness to the revocation. Your attending physician or other health
care provider shall
make your revocation a part of your medical records.
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Ancillary Effect of
Executing Living Will
The making of a declaration does not affect in any manner the sale,
procurement, or issuance of any policy of life insurance, nor does it
modify the terms of an existing policy of life insurance. A policy
of life insurance is not legally impaired or invalidated in any manner by
the withholding or withdrawal of life sustaining procedures from an
insured qualified patient, notwithstanding any term of the policy to the contrary.
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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 and appear
before a notary public for signing. 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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