DIRECTIVE TO PHYSICIANS

Directive made this _________________ day of ___________. I, __________________, being of sound mind, willfully and voluntarily make known my desire that my life shall not be artificially prolonged under the circumstances set forth below, do hereby declare:
1. If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two physicians, and where the application of life-sustaining procedures would serve only to artificially prolong the moment of my death and where my physician determines that my death is imminent whether or not life-sustaining procedures are utilized, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally,
2. In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this directive shall be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.
3. If I have been diagnosed as pregnant and that diagnosis is known to my physician, this directive shall have no force or effect during the course of my pregnancy.
4. I have been diagnosed and notified at least 14 days ago as having a terminal condition by __________________, M.D. whose address is ___________, __________.

I understand that if I have not filed in the physicians name and address, it shall be presumed that I did not have a terminal condition when I made out this directive.
5. This directive shall have no force and effect five years from the date filled in above.
6. I understand the full import of this directive and I am emotionally and mentally competent to make this directive.

_________________________________________________

The Declarant has been personally known to me and I believe him or her to be of sound mind.

Witness __________________________________________________

Witness __________________________________________________

Directive to Physicians as Provided by the California Health and Safety Code: Section 7187
Review List

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 California. 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.

DIRECTIVE TO PHYSICIANS

Date __________________

I, _______________, being of sound mind, intentionally and voluntarily declare:
1. If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two physicians, and where the application of life-sustaining procedures would serve only to artificially prolong the moment of my death and where my physician determines that my death is imminent whether or not life-sustaining procedures are utilized, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally,
2. It is my intention that this directive shall be honored by my family and attending physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.
3. If I have been diagnosed as pregnant and that fact is known to my physician, this directive shall have no force or effect during the course of my pregnancy. I understand the full import of this directive and I am emotionally and mentally competent to execute it.

Signed _________________________________________________

STATE OF _______
COUNTY OF __________

Dated: _________________________

Then and there personally appeared the within named ________________________________ and __________________________, who, being duly sworn, depose and say: That they witnessed the execution of the within Directive to Physicians of the within named _______________, that said declarant subscribed said Directive to Physicians and declared the same to be his Directive to Physicians in their presence, that they thereafter subscribed the same as witnesses in the presence of said declarant and in the presence of each other and at the request of said declarant; that the said declarant at the time of the execution of said Directive
to Physicians appeared to them to be of full age and of sound mind and memory, and that they make this affidavit at the request of said declarant.

________________________________________
Witness
________________________________________
Witness

Subscribed to and sworn to before me this ________ day of _________, 20_____.

_____________________________________________
Notary Public

Directive to Physicians as Provided by Nevada Revised Statutes, Section 449.610
Review List

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 Nevada. 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.

DIRECTIVE TO PHYSICIANS

Directive made this _________________ day of ___________. I ____________, being of sound mind, willfully and voluntarily make known my desire that my life shall not be artificially prolonged under the circumstances set forth below, and do hereby declare:
1. If at any time I should have an incurable condition caused by injury, disease or illness certified to be a terminal condition by two physicians, and where the application of life- sustaining procedures would serve only to artificially prolong the moment of my death and where my attending physician determines that my death is imminent whether or not life-sustaining procedures are utilized, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally.
2. In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this directive shall be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.
3. If I have been diagnosed as pregnant and that diagnosis is known to my physician, this directive shall have no force or effect during the course of my pregnancy.
4. I have been diagnosed and notified at least 14 days ago as having a terminal condition by _________________, M.D., whose address is ____________, ________.

I understand that if I have not filed in the physician’s name and address, it shall be presumed that I did not have a terminal condition when I made out this directive.
5. This directive shall be in effect until revoked.
6. I understand the full import of this directive and I am emotionally and mentally competent to make this directive.
7. I understand that I may revoke this directive at any time.

Signed _________________________________________________

City of residence: _______________
County of residence: _____________
State of residence: ______________

The Declarant has been personally known to me and I believe him or her to be of sound mind. I am not related to the Declarant by blood or marriage, nor would I be entitled to any portion of the Declarant’s estate on his decease, nor am I the attending physician of Declarant or an employee of the attending physician or a health facility in which the Declarant is a patient or any person who has a claim against any portion of the estate of the Declarant upon his decease.

Witness:

__________________________________________________

Witness:

__________________________________________________

Witness:

__________________________________________________

STATE OF TEXAS
COUNTY OF _______________________

Before me, the undersigned authority, on this day personally appeared __________________, __________________________ and __________________________ and _______________________________ known to me to be the Declarant and witnesses whose names are subscribed to the foregoing instrument in their respective capacities, and, all of said persons being by me duly sworn, the Declarant _________________ declared to me and to the said witnesses in my presence that the said instrument is his Directive to Physicians, and that he willingly and voluntarily made and executed it as his free act and deed for the purposes therein expressed.

Declarant:

___________________________________________________________

Subscribed and acknowledged before me by the said Declarant _____________ and by the said witnesses ________________________ and _____________________________ on This ______________ day of ___________________________________________, 20______.

______________________________________________
Notary Public in and for
___________________________ County, Texas

Directive to Physicians as Provided by Texas Natural Death Act: Section 3
Review List

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 Texas. 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.

DIRECTIVE TO PHYSICIANS

Directive made this _________________ day of ___________. I _____________________, being of sound mind, willfully and voluntarily make known my desire that my life shall not be artificially prolonged under the circumstances below:
1. In the absence of my ability to give directions regarding the use of artificial life-sustaining procedures as result of the disease process of my terminal condition, it is my intention that such artificial life-sustaining procedures should not be used when they would serve only to artificially prolong the moment of my death and where my physician determines that my death is imminent whether or not life-sustaining procedures are utilized.
2. I have been diagnosed and notified that I have a terminal condition known as _____________ by ___________ whose address is ___________________, and whose telephone number is ____________.
3. This directive shall have no force and effect five years from the date filled in above.
4. I understand the full import of this directive and I am emotionally and mentally competent to make this directive.

Signed _________________________________________________

STATE OF IDAHO
COUNTY OF _________

We, _________________________, _______________________, and _____________________________, the qualified patient and the witnesses respectively, who names are signed to the attached and foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the qualified patient signed and executed the directive and the he signed willingly and he executed it as his free and voluntary act for the purposes therein expressed; and that each of the witnesses, in the presence and hearing of the qualified patient signed the directive as witness and that to the best of his knowledge the qualified patient was at the time 18 or more years of age, of sound mind and under no constraint or undue influence. We the undersigned witnesses further declare that we are not related to the qualified patient by blood or marriage; that we are not entitled to any portion of the estate of the qualified patient upon his decease under any will or codicil thereto presently existing or by operation of law then existing; that we are not the attending physician, an employee of the attending physician or a health facility in which the qualified patient is a patient, and that we are not a person who has a claim against any portion of the estate of the qualified patient upon his decease at the present time.

________________________________________________
Qualified Patient

Subscribed, sworn to and acknowledged before me by _______________________, the qualified patient, and subscribed and sworn to before me by _______________________ and _____________________, witnesses, this __________ day of _________________, 20_______.

________________________________________________
Notary Public for the State of Idaho

Residing at __________________________, Idaho

Directive to Physicians as Provided by Idaho Natural Death Act, Idaho Code Section 39-4504
Review List

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 Idaho. 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.