TO: My family, physicians and all
those concerned with my care
I,_______________, the undersigned "principal", presently residing at ________________, _____,and being an adult of sound mind, make this declaration as a directive to be followed if for any reason I become unable to make or communicate decisions regarding my medical care.
I do not want medical treatment that will keep me alive if I am unconscious and there is no reasonable prospect that I will ever be conscious again (even if I am not going to die soon in my medical condition) or if I am near death from an illness or injury with no reasonable prospect of recovery. The procedures and treatment to be withheld and withdrawn include, without limitation, surgery, antibiotics, cardiac and pulmonary resuscitation, respiratory support, and artificially administered feeding and fluids. I direct that treatment be limited to measures to keep me comfortable and to relieve pain, even if such measures shorten my life.
[OPTIONAL] I wish to live out my last days at home rather than in a hospital, if it does not jeopardize the chance of my recovery to a meaningful and conscious life and does not impose an undue burden on my family.
[OPTIONAL] If, upon my death, any of my tissue or organs would be of value for transplantation, therapy, advancement of medical or dental science, research, or other medical, educational or scientific purpose, I freely give my permission to the donation of such tissue or organs.
Additional provisions:
These directions are the exercise of my legal right to refuse treatment. Therefore, I expect my family, physicians, health care facilities and all concerned with my care to regard themselves as legally and morally bound to act in accordance with my wishes, and in so doing to be free from any liability for having followed my directions.
IN WITNESS WHEREOF, I have executed this declaration, as my free and voluntary act and deed, this ____day of _________, 2005.
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Principal's name:
WITNESS:
We,the undersigned witnesses, each hereby attest and declare under penalty of perjury under the laws of the Commonwealth of Massachusetts that: (1) the foregoing instrument was personally signed by the above principle in my presence, and thereupon I, at his/her request and in his/her presence and in the presence of the other witnesses, have hereunto subscribed my name as a witness; (2) I did not sign the above signature of said principle for or at his/her direction; (3) I personally know the above principle and believe him/her to be of sound mind and under no constraint, duress, fraud or undue influence; (4) I am not related to the above principle by blood, marriage or adoption; (5) I am not entitled (to the best of my knowledge and belief) to any portion of the estate of the above principle upon his/her death under any will or codicil or by operation of law; (6) I do not have any present or inchoate claim against any portion of the estate of the above principle (7) I do not have any financial responsibility for the medical care of the above principle (8) I am not a physician or an employee of any physician, and I am not an operator or employee of, or patient in, any hospital, health care provider, residential care facility, community care facility or similar institution; and (9) I am at least 18 years of age.
Dated: _________, 2005
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residing at
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residing at
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