Declaration of a Durable Power of Attorney for Health Care Only
1. Declaration.
A. Life Sustaining Procedures. Declaration made on this date, _________, I, ________ (“Declarant”), being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, and do hereby declare:
If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition or a permanently unconscious condition by two (2) physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life-sustaining procedures are utilized, or that I will remain in a permanently unconscious condition, and where the application of life-sustaining procedures would serve only to prolong artificially the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, sustenance, or the performance of any medical procedure deemed necessary to provide me with comfortable care.
B. Hydration and Nutrition. I realize that situations could arise in which the only way to allow me to die would be to discontinue artificial nutrition and hydration. In carrying out any instruction I have given under this section, I authorize that artificial nutrition and hydration BE STARTED, or if started, BE CONTINUED….
