34-12D-3 Declaration--Sample form.
A declaration may, but need not, be in the following
LIVING WILL DECLARATION
This is an important legal document. A living will directs the medical treatment you are to
receive in the event you are in a terminal condition and are unable to participate in your own medical
decisions. This living will may state what kind of treatment you want or do not want to receive.
Prepare this living will carefully. If you use this form, read it completely. You may want to seek
professional help to make sure the form does what you intend and is completed without mistakes.
This living will remains valid and in effect until and unless you revoke it. Review this living will
periodically to make sure it continues to reflect your wishes. You may amend or revoke this living
will at any time by notifying your physician and other health care providers. You should give copies
of this living will to your family, your physician, and your health care facility. This form is entirely
optional. If you choose to use this form, please note that the form provides signature lines for you,
the two witnesses whom you have selected, and a notary public.
TO MY FAMILY, HEALTH CARE PROVIDER, AND ALL THOSE CONCERNED WITH MY
I, __________ direct you to follow my wishes for care if I am in a terminal condition, my death
is imminent, and I am unable to communicate my decisions about my medical care.
With respect to any life-sustaining treatment, I direct the following:
(Initial only one of the following options. If you do not agree with either of the following options,
space is provided below for you to write your own instructions.)
_ If my death is imminent or I am permanently unconscious, I choose not to prolong my life. If
life sustaining treatment has been started, stop it, but keep me comfortable and control my pain.
_ Even if my death is imminent or I am permanently unconscious, I choose to prolong my life.
_ I choose neither of the above options, and here are my instructions should I become terminally
ill and my death is imminent or I am permanently unconscious:
Artificial Nutrition and Hydration: food and water provided by means of a tube inserted into the
stomach or intestine or needle into a vein.
With respect to artificial nutrition and hydration, I direct the following:
(Initial only one)
_ If my death is imminent or I am permanently unconscious, I do not want artificial nutrition and
hydration. If it has been started, stop it.
_ Even if my death is imminent or I am permanently unconscious, I want artificial nutrition and
Date: __________________ _______________________________________
(your address) (type or print your signature)
The declarant voluntarily signed this document in my presence.
On this the ______ day of ________, ______, the declarant, _______________, and witnesses
_______________, and _______________ personally appeared before the undersigned officer and
signed the foregoing instrument in my presence. Dated this ______ day of ________, ______.
______________________________________ Notary Public
My commission expires: ____________________________.
Source: SL 1991, ch 273, § 3; SL 2007, ch 193, § 2.