I have the primary right to make my own decisions concerning treatment that might unduly prolong the dying process. By this declaration I express to my physician, family and friends my intent. If I should have a terminal condition it is my desire that my dying not be prolonged by administration of death-prolonging procedures. If my condition is terminal and I am unable to participate in decisions regarding my medical treatment, I direct that my attending physician to withhold or withdraw medical procedures that merely prolong the dying process and are not necessary to my comfort or to alleviate pain. It is not my intent to authorize affirmative or deliberate acts or omissions to shorten my life rather only to permit the natural process of dying.

Signed this ____________________ day of _______________

________________________________________________________________

Signature: __________________
City of residence: __________
County of residence: ________
State of residence: _________

The Declarant is known to me, is eighteen years of age or older, of sound mind and voluntarily signed this document in my presence.

________________________________________________________________

Witness
Address:

________________________________________________________________

Witness
Address:

Declaration in Conformance with Missouri Statutes 459.015
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This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in Missouri. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1. Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.

DECLARATION

If I should have an incurable or irreversible condition that will cause my death within a reasonable short time, it is my desire that my life not be prolonged by administration of life-sustaining procedures. If my condition is terminal and I am unable to participate in decisions regarding my medical treatment, I direct my attending physician to withhold or withdraw procedures that merely prolong the dying process and are not necessary to my comfort or freedom from pain. It is my intention that this declaration shall be valid until revoked by me.

Signed this ___________________ day of ______________

________________________________________________________________
Signature: ______________
City of residence: __________________
County of residence: ________________
State of residence: _________________

The Declarant is known to me and voluntarily signed this document in my presence.

Witness:

_____________________________________________________________

Witness:

_____________________________________________________________

Declaration as Provided by Montana Stats. 50-9-104
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This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in Montana. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1. Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.

DECLARATION

On this _________________ day of ___________, I ________ ______, being of sound mind, willfully and voluntarily direct that my dying shall not be artificially prolonged under the circumstances set forth in this declaration:

If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two (2) physicians who have personally examined me, one (1) of whom shall be my attending physician, and the physicians have determined that my death is imminent whether or not life-sustaining procedures are utilized and where the application of such procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, and the administration of food and water, and the performance of any medical procedure that is necessary to provide comfort care or to alleviate pain. In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this declaration shall be honored by my family and physician(s) as the final expression of my legal right to control my medical care or treatment. I am legally competent to make this declaration, and I understand its full import.

Signed _________________________________________________________
Address: _______________________________________________________

Under penalty of perjury, we state that this declaration was signed by ______________ in the presence of the undersigned who, at ______________’s request, in ______________’s presence, and in the presence of each other, have hereunto signed our names as witnesses this _______________ day of ___________________ 20_______. Further, each of us, individually, states that:

The Declarant is known to me, and I believe the Declarant to be of sound mind. I did not sign the Declarant’s signature to this declaration. Based upon information and belief, I am not related to the Declarant by blood or marriage, a creditor of the Declarant, entitled to any portion of the estate of the Declarant under any existing testamentary instrument of the Declarant, entitled to any financial benefit by reason of the death of the Declarant, financially or otherwise responsible for the Declarant’s medical care, nor the employee of any such person or institution.

________________________________________________
Address:

________________________________________________
Address:

Declaration as Provided by Maryland Health-General Code Section 5-602
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This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in Maryland. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1. Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.

DECLARATION

A. Statement of Declarant

Declaration made this __________________ day of _____________, 20_______. I, _________________ being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, and do hereby declare:

If at any time I should have an incurable or irreversible condition certified to be terminal by two physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that I am unable to make decisions concerning my medical treatment, and that without administration of life-sustaining treatment my death will occur in a relatively short time, and where the application of life-sustaining procedures would serve only to prolong artificially the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, nourishment, or fluids or the performance of any medical procedure deemed necessary to provide me with comfort or to alleviate pain.

I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration.

Signed:

________________________________________________________________

STATE OF ____________________
COUNTY OF ___________________

B. Statement of Witnesses

I am at least 18 years of age and not related to the Declarant by blood, marriage or adoption; and not the attending physician, an employee of the attending physician, or an employee of the medical care facility in which the Declarant is a patient.

The Declarant is personally known to me and I believe the Declarant to be of sound mind.

Witness:

_______________________________________________________________
Address:

Witness:

_______________________________________________________________
Address:

C. Notarization

Subscribed, sworn to and acknowledged before me by _________________, the Declarant, and subscribed and sworn to before me by ___________________ and ___________________, witnesses, this ______________ day of ________________________, 20_______.

_____________________________________

Official Capacity: _________________

Declaration as Provided by Hawaii Revised Statutes Chapter 327D, Section 4
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This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in Hawaii. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1. Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.

DECLARATION

If I should have an incurable or irreversible condition that will cause my death within a short time, and if I am unable to participate in decisions regarding my medical treatment, I direct my attending physician to withhold or withdraw procedures that merely prolong the dying process and are not necessary to my comfort or freedom from pain.

Signed this _____________ day of _______________________________
date month year

Signature ______________________________________________

The Declarant is known to me and voluntarily signed this document in my presence.

Witness ________________________________________________

Address:

Witness ________________________________________________

Address:

Declaration Provided by Maine Revised Statutes Title 22 Section 2922
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This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in Maine. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1. Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.

DECLARATION AS TO MEDICAL OR SURGICAL TREATMENT

I _____________, being of sound mind and at least eighteen years of age, direct that my life shall not be artificially prolonged under the circumstances set forth below and hereby declare that:
1. If at any time my attending physician and one other physician certify in writing that:
a. I have an injury, disease, or illness which is not curable or reversible and which, in their judgment, is a terminal condition; and
b. For a period of forty-eight consecutive hours or more, I have been unconscious, comatose, or otherwise incompetent so as to be unable to make or communicate responsive decisions concerning my person; then,

I direct that life-sustaining procedures shall be withdrawn and withheld, it being understood that life-sustaining procedures shall not include any medical procedure or intervention for nourishment or considered necessary by the attending physician to provide comfort or alleviate pain.

2. I execute this declaration, as my free and voluntary act, this ___________________ day of _____________________, 20______.

By ___________________________________
___________________________, Declarant

The foregoing instrument was signed and declared by ________ _______ to be his declaration, in the presence of us, who, in his presence, in the presence of each other, and at his request have signed our names below as witnesses, and we declare that, at the time of the execution of this instrument, the Declarant, according to our best knowledge and belief, was of sound mind and under no constraint or undue influence.

Dated at _______, _______, this ___________ day of ___________________, 20________.

________________________________________________________
Name and address

________________________________________________________
Name and address

STATE OF COLORADO
COUNTY OF ______________

Subscribed and sworn to before me by __________________, the Declarant, and __________________________________, and _______________________________, witnesses, as the voluntary act and deed of the Declarant, this ________________ day of __________ 20________.

________________________________________
Notary Public

Declaration Provided by Colorado Medical Treatment Decision Act: Colorado Statutes 15-18-104
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This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in Colorado. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1. Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.

DECLARATION OF __________________

If I should have an incurable or irreversible condition that will cause my death within a relatively short time, it is my desire that my life not be prolonged by administration of life-sustaining procedures. If my condition is terminal and I am unable to participate in decisions regarding my medical treatment, I direct my attending physician to withhold or withdraw procedures that merely prolong the dying process and are not necessary to my comfort or freedom from pain.

Signed this _______________ day of _______________, 20_____

Signature: _____________________________________________________

The Declarant is known to me and voluntarily signed this document in my presence.

Witness: __________________________________________________

Address:

Witness: __________________________________________________

Address:

Declaration as Provided by Iowa Code 144A.3
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This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in Iowa. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1. Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.