Nurturing/ Teaching Courses
A Living Will
1. Statement of (Name)
If the time comes when I am incapacitated to the point that I no longer actively take part in decisions for my own, and am unable to direct my physician as to my own care, I wish this statement to stand as a testament of my wishes. I , (name) , request that I be allowed to die and not to be kept alive through life support systems if my condition is deemed terminal. I do not intend any direct taking of my life, but only that my dying not be unreasonably prolonged. This request is made, after careful consideration, while I am of sound mind.
2. Living Will
To my family, my physician, my lawyer, and to all others whom it may concern:
Death is as much a reality as birth, growth, maturity and old age; it is the one certainty of life. If the time comes when I can no longer take part in decisions for my own future, let this statement stands as an expression of my wishes and directions, while I am still of sound mind.
If at such a time the situation should arise in which there is no reasonable expectation of my recovery from extreme physical and mental disability, I direct that I be allowed to die and not to be kept alive by medications, artificial means, or “heroic measures.” I do, however ask that medication be mercifully administered to me to alleviate suffering, even though this may shorten my remaining life.
This statement is made after careful consideration and is in accordance with my strong convictions and beliefs. I want the wishes and directions here expressed carried out to the extent permitted by law. Insofar as they are no legally enforceable, I hope that those to whom this Will is addressed will regard themselves as morally bound by these provisions.
Copies of this request have been given to ___________________________
If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two (2) physicians who have personally examined me, one (1) of whom shall be my attending physician, and the physicians have determined that my death is imminent and will occur whether or not life-sustaining procedures are utilised and where the application of such procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, the administration of food and water, and the performance of any medical procedure that is necessary to provide comfort and 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 honoured by my family and physician(s) as the final expression of my right to control my medical care and treatment.
Declaration made this ________ day of _______________ (month, year).
I, _______________________________, being of sound mind, wilfully and
voluntarily direct that my dying shall not be artificially prolonged under the
circumstances set forth in this declaration.
I am legally competent to make this declaration, and I understand its full import.
Under penalty of perjury, we state that this declaration was signed by _______________ in the presence of the undersigned who, at his/her request, in his/her presence, and in the presence of each other, have hereunto signed our names and witnessed this______ day of
____________,19__, and declare: The declarant is personally known to me, and I believe the declarant to be of sound mind. I did not sign the declarant’s signature to this declaration. Based upon information and belief, I am not related to the declarant by blood or marriage, a creditor of the declarant, entitled to any portion of the estate of the declarant under any existing testamentary instrument to the declarant, financially or otherwise responsible for the declarant’s medical care, or an employee of any such person or institution.
 Beckwith, Francis J. & Geisler, Norman L., Matters of Life and Death (Grand Rapids, MI : Baker House,1991) p. 372 - 374
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