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Declaration made this day ______ of
__________ , 2000, I, JOHN DOE, willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do hereby declare that, if at any time I am both mentally and physically incapacitated
__________ and I have a terminal condition
or __________ and I have an end-stage condition
or __________ and I am in a persistent vegetative state
and if my attending or treating physician and another consulting physician have determined that there is no reasonable medical probability of my recovery from such condition, I direct that
life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain.
It is my intention that this declaration be honored by my family and
physician as the final expression of my legal right to refuse medical or
surgical treatment and to accept the consequences for such refusal.
In the event that I have been determined to be unable to provide express
and informed consent regarding the withholding, withdrawal, or
continuation of life-prolonging procedures, I wish to designate the
following persons in the following order as my surrogate to carry out the
provisions of this declaration:
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I understand the full import of this declaration, and I am emotionally and
mentally competent to make this declaration. Additional Instructions
(optional):
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JOHN DOE
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