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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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Designation of Agent
This
living will gives your health care providers or your designated agent (proxy) the
power and guidance to make health care decisions according to your wishes
when you are in a terminal condition and cannot do so. This document
may include what kind of treatment you want or do not want and under what
circumstances you want these decisions to be made. You may state where you
want or do not want to receive any treatment. Your agent has the same right
as you have to examine your medical records and to consent to their
disclosure for purposes related to your health care or insurance unless
you limit this right in this document.
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Designation
of Physician
This living will allows you to
designate a physician to have primary responsibility for your health care.
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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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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.
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Ancillary Effect of
Executing Living Will
Death resulting from the withholding or withdrawal of life-sustaining
treatment does not constitute, for any purpose, a suicide or homicide.
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 your living will you should sign it before a notary
public OR in front of two witnesses. If you sign in front of two witnesses
pay particular attention to the qualifications contained in the witness
statement. You should provide a copy of your completed
living will to your attending physician and other health care providers
and they shall make it a part of your medical records. You should also
give a copy to trusted family members.
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If
at any time you should have an
incurable condition certified in writing by your attending physician and
one other qualified physician to be terminal or 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 to provide you comfort care. 