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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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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
You must sign your living will in front of two witnesses and a Notary or Clerk of Superior
Court. Pay particular attention to the qualifications of the
witnesses. The original or a copy should be submitted to your
physician for entry in your medical records. Copies should be made and
given 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would only prolong the dying process be withheld or withdrawn, and that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.