65-28,103.Same; declaration authorizing; effectduring pregnancy of qualified patient; duty to notify attending physician; formof declaration; severability of directions.(a) Any adult person may execute a declaration directingthe withholding or withdrawal of life-sustaining procedures in a terminalcondition. The declaration made pursuant to this act shall be: (1) In writing;(2) signed by the person making the declaration, or by another person inthe declarant's presence and by the declarant's expressed direction; (3)dated; and (4)(A) signed in the presence of two or more witnesses at least 18years of age neither of whom shall be the person who signedthe declaration on behalf of and at the direction of the person making thedeclaration, related to the declarant by blood or marriage, entitled toany portion of the estate of the declarant according to the laws of intestatesuccession of this state or under any will of the declarant or codicil thereto,or directly financially responsible for declarant's medical care; or (B)acknowledged before a notary public. The declarationof a qualified patient diagnosed as pregnant by the attending physician shallhave no effect during the course of the qualified patient's pregnancy.
(b) It shall be the responsibility of declarant to provide for notificationto the declarant's attending physician of the existence ofthe declaration.An attending physician who is so notified shall make the declaration, ora copy of the declaration, a part of the declarant's medical records.
(c) The declaration shall be substantially in the following form, butin addition may include other specific directions. Should any of the otherspecific directions be held to be invalid, such invalidity shall not affectother directions of the declaration which can be given effect without theinvalid direction, and to this end the directions in the declaration areseverable.
DECLARATION
Declaration made this ___________ day of ______ (month, year). I,_____________, being of sound mind, willfully and voluntarily make knownmy desire that my dying shall not be artificially prolonged under thecircumstances set forth below, do hereby declare:
If at any time I should have an incurable injury, disease, or illness certifiedto be a terminal condition by two physicians who have personally examinedme, one of whom shall be my attending physician, and the physicians havedetermined that my death will occur whether or not life-sustaining proceduresare utilized and where the application of life-sustaining procedures wouldserve only to artificially prolong the dying process, I direct that suchprocedures be withheld or withdrawn, and that I be permitted to die naturallywith only the administration of medication or the performance of any medicalprocedure deemed necessary to provide me with comfort care.
In the absence of my ability to give directions regarding the use of suchlife-sustaining procedures, it is my intention that this declaration shallbe honored by my family and physician(s) as the final expression of my legalright to refuse medical or surgical treatment and accept the consequencesfrom such refusal.
I understand the full import of this declaration and I am emotionally andmentally competent to make this declaration.
Signed ____________________________________
City, County and State
of Residence ______________________________
The declarant has been personally known to me and I believethe declarant to be of sound mind.I did not sign the declarant's signature above for or at the direction of the declarant. I am not related to the declarant by blood or marriage,entitled to any portion of the estate of the declarant according to thelaws of intestate succession or under any will of declarant or codicil thereto,or directly financially responsible for declarant's medical care.
65-28,103.Same; declaration authorizing; effectduring pregnancy of qualified patient; duty to notify attending physician; formof declaration; severability of directions.(a) Any adult person may execute a declaration directingthe withholding or withdrawal of life-sustaining procedures in a terminalcondition. The declaration made pursuant to this act shall be: (1) In writing;(2) signed by the person making the declaration, or by another person inthe declarant's presence and by the declarant's expressed direction; (3)dated; and (4)(A) signed in the presence of two or more witnesses at least 18years of age neither of whom shall be the person who signedthe declaration on behalf of and at the direction of the person making thedeclaration, related to the declarant by blood or marriage, entitled toany portion of the estate of the declarant according to the laws of intestatesuccession of this state or under any will of the declarant or codicil thereto,or directly financially responsible for declarant's medical care; or (B)acknowledged before a notary public. The declarationof a qualified patient diagnosed as pregnant by the attending physician shallhave no effect during the course of the qualified patient's pregnancy.
(b) It shall be the responsibility of declarant to provide for notificationto the declarant's attending physician of the existence ofthe declaration.An attending physician who is so notified shall make the declaration, ora copy of the declaration, a part of the declarant's medical records.
(c) The declaration shall be substantially in the following form, butin addition may include other specific directions. Should any of the otherspecific directions be held to be invalid, such invalidity shall not affectother directions of the declaration which can be given effect without theinvalid direction, and to this end the directions in the declaration areseverable.
DECLARATION
Declaration made this ___________ day of ______ (month, year). I,_____________, being of sound mind, willfully and voluntarily make knownmy desire that my dying shall not be artificially prolonged under thecircumstances set forth below, do hereby declare:
If at any time I should have an incurable injury, disease, or illness certifiedto be a terminal condition by two physicians who have personally examinedme, one of whom shall be my attending physician, and the physicians havedetermined that my death will occur whether or not life-sustaining proceduresare utilized and where the application of life-sustaining procedures wouldserve only to artificially prolong the dying process, I direct that suchprocedures be withheld or withdrawn, and that I be permitted to die naturallywith only the administration of medication or the performance of any medicalprocedure deemed necessary to provide me with comfort care.
In the absence of my ability to give directions regarding the use of suchlife-sustaining procedures, it is my intention that this declaration shallbe honored by my family and physician(s) as the final expression of my legalright to refuse medical or surgical treatment and accept the consequencesfrom such refusal.
I understand the full import of this declaration and I am emotionally andmentally competent to make this declaration.
Signed ____________________________________
City, County and State
of Residence ______________________________
The declarant has been personally known to me and I believethe declarant to be of sound mind.I did not sign the declarant's signature above for or at the direction of the declarant. I am not related to the declarant by blood or marriage,entitled to any portion of the estate of the declarant according to thelaws of intestate succession or under any will of declarant or codicil thereto,or directly financially responsible for declarant's medical care.
65-28,103.Same; declaration authorizing; effectduring pregnancy of qualified patient; duty to notify attending physician; formof declaration; severability of directions.(a) Any adult person may execute a declaration directingthe withholding or withdrawal of life-sustaining procedures in a terminalcondition. The declaration made pursuant to this act shall be: (1) In writing;(2) signed by the person making the declaration, or by another person inthe declarant's presence and by the declarant's expressed direction; (3)dated; and (4)(A) signed in the presence of two or more witnesses at least 18years of age neither of whom shall be the person who signedthe declaration on behalf of and at the direction of the person making thedeclaration, related to the declarant by blood or marriage, entitled toany portion of the estate of the declarant according to the laws of intestatesuccession of this state or under any will of the declarant or codicil thereto,or directly financially responsible for declarant's medical care; or (B)acknowledged before a notary public. The declarationof a qualified patient diagnosed as pregnant by the attending physician shallhave no effect during the course of the qualified patient's pregnancy.
(b) It shall be the responsibility of declarant to provide for notificationto the declarant's attending physician of the existence ofthe declaration.An attending physician who is so notified shall make the declaration, ora copy of the declaration, a part of the declarant's medical records.
(c) The declaration shall be substantially in the following form, butin addition may include other specific directions. Should any of the otherspecific directions be held to be invalid, such invalidity shall not affectother directions of the declaration which can be given effect without theinvalid direction, and to this end the directions in the declaration areseverable.
DECLARATION
Declaration made this ___________ day of ______ (month, year). I,_____________, being of sound mind, willfully and voluntarily make knownmy desire that my dying shall not be artificially prolonged under thecircumstances set forth below, do hereby declare:
If at any time I should have an incurable injury, disease, or illness certifiedto be a terminal condition by two physicians who have personally examinedme, one of whom shall be my attending physician, and the physicians havedetermined that my death will occur whether or not life-sustaining proceduresare utilized and where the application of life-sustaining procedures wouldserve only to artificially prolong the dying process, I direct that suchprocedures be withheld or withdrawn, and that I be permitted to die naturallywith only the administration of medication or the performance of any medicalprocedure deemed necessary to provide me with comfort care.
In the absence of my ability to give directions regarding the use of suchlife-sustaining procedures, it is my intention that this declaration shallbe honored by my family and physician(s) as the final expression of my legalright to refuse medical or surgical treatment and accept the consequencesfrom such refusal.
I understand the full import of this declaration and I am emotionally andmentally competent to make this declaration.
Signed ____________________________________
City, County and State
of Residence ______________________________
The declarant has been personally known to me and I believethe declarant to be of sound mind.I did not sign the declarant's signature above for or at the direction of the declarant. I am not related to the declarant by blood or marriage,entitled to any portion of the estate of the declarant according to thelaws of intestate succession or under any will of declarant or codicil thereto,or directly financially responsible for declarant's medical care.
