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procedures be withheld or withdrawn, and that I be permitted to die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 __________________________________________________ Date: _______________
Witness __________________________________________________ Date: _______________
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.