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This declaration is made on _________[date].

I, _________, willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do declare:

If at any time I have a terminal condition and if my attending or treating physician and another consulting physician have determined that there is no medical probability of my recovery from that condition, I direct that life-prolonging procedures be withheld or withdrawn, when the application of the procedures would serve only to prolong, artificially, the process of dying, and that I be permitted to die naturally with only the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 or care or to alleviate pain.

It is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences for that refusal.

In the event that I have been determined to be unable to provide express and informed consent regarding the withholding, withdrawal, or continuation of life-prolonging procedures, I wish to designate, as my surrogate to carry out the provisions of this declaration:

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

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[Signature]

On _________[date], _________[name], known to us to be the person whose signature appears at the end of the above directive, declared to us, the undersigned, that the above directive, consisting of _________ pages, including the page on which we have signed as witnesses, was _________[his or her] directive. _________[He or She] then signed the directive in our presence and, at _________[his or her] request, in _________[his or her] presence and in the presence of each other, we now sign our names as witnesses.

_________[Name] declarant has been personally known to us and we believe _________[him or her] to be of sound mind. We are not related to _________[name] by blood or marriage, nor would we be entitled to any part of _________[name's] estate on _________[name's] death, nor are we the attending physicians of _________[name] or an employee of the attending physician or a health facility in which _________[name] is a patient, or a patient in the health care facility in which _________[name] is a patient, or any person who has a claim against any part of the estate of the _________[name] on _________[name's] death.

______________________________, residing at
[Signature]

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[Street, city, state]

______________________________, residing at
[Signature]

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[Street, city, state]

______________________________, residing at
[Signature]

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[Street, city, state]