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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
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prolong the dying process be withheld or withdrawn, and that you be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,
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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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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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 given the option in
preparing your living will of donating any body organs or specific body
organs including tissues and eyes.
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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
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 must gather two witnesses
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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