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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. You may also write in any
additional instructions you desire.
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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 Physician(s)
An attending physician or health care
provider who refuses to comply with your declaration shall make the
necessary arrangements to effect your transfer to another physician who
will effectuate the provisions of you declaration of living will.
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Revocation
A declaration may be
revoked at any time and in any manner by which you are able to communicate
an intent to revoke, without regard to mental or physical condition.
A revocation is only effective as to the attending physician or any health
care provider upon communication to that physician or health care provider
by you or by another who witnesses your 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 printed
out your declaration you must sign in front of two witnesses both over the
age of 18. You should then submit the original or a copy to your
physician for entry in your medical records.
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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. 