Life Sustaining Statute, Indiana

Answer 1

Directive to Physicians as Provided by Texas Natural Death Act: Section 3

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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, and do hereby declare:

1. If at any time I should have an incurable condition caused by 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 attending 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death is imminent whether or not life-sustaining procedures are utilized, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally.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 be in effect until revoked.

6. I understand the full import of this directive and I am emotionally and mentally competent to make this directive.

7. I understand that I may revoke this directive at any time.

Signed _________________________________________________

City of residence: _______________

County of residence: _____________

State of residence: ______________

The Declarant has been personally known to me and I believe him or her to be of sound mind. I am not related to the Declarant by blood or marriage, nor would I be entitled to any portion of the Declarants estate on his decease, nor am I the attending physician of Declarant or an employee of the attending physician or a health facility in which the Declarant is a patient or any person who has a claim against any portion of the estate of the Declarant upon his decease.

Witness:

__________________________________________________

Witness:

__________________________________________________

Witness:

__________________________________________________

STATE OF Texas

COUNTY OF _______________________

Before me, the undersigned authority, on this day personally appeared __________________, __________________________ and __________________________ and _______________________________ known to me to be the Declarant and witnesses whose names are subscribed to the foregoing instrument in their respective capacities, and, all of said persons being by me duly sworn, the Declarant _________________ declared to me and to the said witnesses in my presence that the said instrument is his Directive to Physicians, and that he willingly and voluntarily made and executed it as his free act and deed for the purposes therein expressed.

Declarant:

___________________________________________________________

Subscribed and acknowledged before me by the said Declarant _____________ and by the said witnesses ________________________ and _____________________________ on This ______________ day of ___________________________________________, 20______.

______________________________________________

Notary Public in and for

___________________________ County, Texas

Directive to Physicians as Provided by Texas Natural Death Act: Section 3

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 Texas. Check with a local hospital or doctors 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.

Answer 2

Statutory Declaration in Conformance with Florida Life Prolonging Procedure Act, F.S. 765.05

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DECLARATION OF ________________________

Declaration made this __________ day of _____________ 20________. I ___________ willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, do hereby declare:

If at any time I should have a terminal condition, and if my attending physician has determined that there can be no recovery from such condition and my death is imminent, I direct that such procedures be withheld or withdrawn, 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.

In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this declaration shall be honored by my family and physicians as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences for such refusal.

If I have been diagnosed as pregnant and that diagnosis is known to my physician, this declaration shall have no force or effect during the course of my pregnancy.

I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration.

_______________________________________

_______________________________________

City of residence: _____________________

County of residence: ___________________

State of residence: ____________________

Date: ________________________

The Declarant has been personally known to me and I believe him or her to be of sound mind.

Witness: ___________________________________________

Witness: ___________________________________________

Date: ___________________________

Statutory Declaration in Conformance with Florida Life Prolonging Procedure Act, F.S. 765.05

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 Florida. Check with a local hospital or doctors 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.

Answer 3

Statutory Declaration in Conformance with Indiana Living Will and Life-Prolonging Procedures Act, Indiana Code 16-8-11-12

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LIVING WILL DECLARATION OF ________________

Declaration made this __________ day of _________________ 20________.

I, _____________, being at least eighteen (18) years old and of sound mind, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below, and I declare:

If at any time I should have an incurable and irreversible injury, disease, or illness certified in writing to be a terminal condition by my attending physician, and my attending physician has determined that my death will occur in a short period of time, and the use of life-prolonging procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the provision of appropriate nutrition and hydration and the administration of medication and the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain.

In the absence of my ability to give directions regarding the use of such life prolonging delaying procedures, it is my intention that this declaration shall be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences of the refusal.

I understand the full import of this declaration.

________________________________________

City of Residence: ____________________

County of Residence: __________________

State of Residence: ___________________

Date: _________________

The Declarant has been personally known to me and I believe him or her to be of sound mind. I did not sign the Declarants signature above for or at the direction of the Declarant. I am not a parent, spouse, or child of the Declarant. I am not entitled to any part of the Declarants estate or directly financially responsible for Declarants medical care. I am competent and at least eighteen (18) years old.

Witness _________________________________________________

Witness _________________________________________________

Date: _______________________

Statutory Declaration in Conformance with Indiana Living Will and Life-Prolonging Procedures Act, Indiana Code 16-8-11-12

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 Indiana. Check with a local hospital or doctors 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.