§ 23-4.11-3 - Declaration relating to use of life sustaining procedures.
SECTION 23-4.11-3
§ 23-4.11-3 Declaration relating to use oflife sustaining procedures. – (a) A competent individual eighteen (18) years of age or older may at any timeexecute a declaration governing the withholding or withdrawal of lifesustaining procedures. The declaration must be signed by the declarant, oranother at the declarant's direction in the presence of two (2) subscribingwitnesses who are not related to the declarant by blood or marriage.
(b) A physician or other health care provider who is provideda copy of the declaration shall make it a part of the declarant's medicalrecord.
(c) A declaration has operative effect only when:
(1) The declaration is communicated to the attendingphysician;
(2) The declarant is determined by the attending physician tobe in a terminal condition; and
(3) The declarant is unable to make treatment decisions.
(d) A declaration may, but need not, be in the followingform:
DECLARATION
I, ]]]]]]]]]]]]]]]]]]]]]]]]]], being of sound mind willfullyand voluntarily make known my desire that my dying shall not be artificiallyprolonged under the circumstances set forth below, do hereby declare:
If I should have an incurable or irreversible condition thatwill cause my death and if I am unable to make decisions regarding my medicaltreatment, I direct my attending physician to withhold or withdraw proceduresthat merely prolong the dying process and are not necessary to my comfort, orto alleviate pain.
This authorization includes ( ) does not include ( ) thewithholding or withdrawal of artificial feeding (check only one box above).
Signed this ]]]]]]]]]] day of ]]]]]]]]]]]]]]]]]],]]]]]]]]]]]]]].
Signature
Address
The declarant is personally known to me and voluntarilysigned this document in my presence.
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Witness Witness
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Address Address