Section 459.015 - Declaration, who may execute requirements of declaration - form - witnesses required, when - notice to physician - filed - where1. Any competent person may execute a declaration directing the withholding or withdrawal of death-prolonging procedures. The declaration made pursuant to sections 459.010 to 459.055 shall be: (2) Signed by the person making the declaration, or by another person in the declarant's presence and by the declarant's expressed direction;(4) If not wholly in the declarant's handwriting, signed in the presence of two or more witnesses at least eighteen years of age neither of whom shall be the person who signed the declaration on behalf of and at the direction of the person making the declaration.2. It shall be the responsibility of the declarant to provide for notification to his attending physician of the existence of the declaration. Upon the request of the patient, the declaration shall be placed in the declarant's medical records as maintained by his attending physician and the medical records of any health facility of which he is a patient.3. The declaration may be in the following form, but it shall not be necessary to use this sample form. In addition, the declaration may include other specific directions. Should any of the other specific directions be held to be invalid, such invalidity shall not affect other directions of the declaration which can be given effect without the invalid declaration, and to this end the directions in the declaration are severable. DECLARATION |
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 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, County and 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 | __________________ |
REVOCATION PROVISION |
I hereby revoke the above declaration. |
| Signed | __________________ |
| | (Signature of Declarant) |
| Date | __________________ |