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CONDITIONS UNDER WHICH YOU MAY EXECUTE A LIVING WILL
If at any time you should have an incurable and irreversible injury, disease, or illness certified in writing to be a terminal condition by your attending physician and one other qualified physician and/or you have been unconscious, comatose, or otherwise incompetent so as to be unable to make or communicate responsible decisions concerning your person, you may direct that such procedures which would only prolong the dying process be withheld or withdrawn, and that you be permitted to die naturally with only the administration of medication, sustenance, or the performance of any medical procedure deemed necessary by your attending physician to provide you with comfort care.
ADDITIONAL INFORMATION ABOUT THIS LIVING WILL
Election of Treatment(s)
After you have completed this form and printed it out, you will be allowed you to check off treatments you want and don't want. Among those are matters which relate to treatment while you are permanently unconscious and the condition is irreversible. You will be given the option of receiving artificial nutrition and hydration and other treatment.
Duty of Attending Physician(s)
When your living will becomes operative, your physician and other health care providers shall act in accordance with its provisions. If your attending physician or other health care provider cannot in good conscience comply with the provisions of your living will or if the policies of the health care provider preclude compliance, your attending physician or health care provider shall so inform you, or, if you are incompetent, shall so inform your agent, or, if you have not designated a health care proxy, shall so inform your family, guardian or other representative. Your physician and health care provider shall make every reasonable effort to assist in the your transfer to another physician or health care provider who will comply with your living will.
Your living will becomes operative when a copy is provided to your attending physician; and you are determined by your attending physician to be incompetent and in a terminal condition or in a state of permanent unconsciousness.
You will be given the option in preparing your living will of donating any body organs or specific body organs including tissues and eyes.
A declaration may be revoked at any time and in any manner by which you are able to communicate an intent to revoke, without regard to mental or physical condition. A revocation is only effective as to the attending physician or any health care provider upon communication to that physician or health care provider by you or by another who witnesses your revocation.
Ancillary Effect of Executing Living Will
The making of a declaration does not affect in any manner the sale, procurement, or issuance of any policy of life insurance, nor does it modify the terms of an existing policy of life insurance. A policy of life insurance is not legally impaired or invalidated in any manner by the withholding or withdrawal of life sustaining procedures from an insured qualified patient, notwithstanding any term of the policy to the contrary.
Executing and Delivering Your Living Will
After you have completed your living will, you must gather two witnesses for signing. The original or a copy should be submitted to your physician for entry in your medical records. If you revoke your living will, you should also submit the original to your physician to be placed in your medical records as well.
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