Indiana § 16-36-4-10 Form of living will declaration

Indiana Statutes

§ 16-36-4-10 — Form of living will declaration

Indiana·Title 16 HEALTH·Art. 36 MEDICAL CONSENT·Ch. 4 Living Wills and Life Prolonging Procedures

The following is the living will declaration form: LIVING WILL DECLARATION Declaration made this _____ day of _______ (month, year). I, _________, being at least eighteen (18) years of age and of sound mind, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below, and I declare: If at any time my attending physician certifies in writing that:

(1)I have an incurable injury, disease, or illness;

(2)my death will occur within a short time; and (3) the use of life prolonging procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the performance or provision of any medical procedure or medic

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The following is the living will declaration
form:
LIVING WILL DECLARATION
Declaration made this _____ day of _______ (month, year). I,
_________, being at least eighteen (18) years of age and of sound
mind, willfully and voluntarily make known my desires that my dying
shall not be artificially prolonged under the circumstances set forth
below, and I declare:
If at any time my attending physician certifies in writing that: (1) I
have an incurable injury, disease, or illness; (2) my death will occur
within a short time; and (3) the use of life prolonging procedures would
serve only to artificially prolong the dying process, I direct that such
procedures be withheld or withdrawn, and that I be permitted to die
naturally with only the performance or provision of any medical
procedure or medication necessary to provide me with comfort care or
to alleviate pain, and, if I have so indicated below, the provision of
artificially supplied nutrition and hydration. (Indicate your choice by
initialing or making your mark before signing this declaration):
__________ I wish to receive artificially supplied nutrition and
hydration, even if the effort to sustain life is futile or excessively
burdensome to me.
__________ I do not wish to receive artificially supplied nutrition
and hydration, if the effort to sustain life is futile or excessively
burdensome to me.
__________ I intentionally make no decision concerning
artificially supplied nutrition and hydration, leaving the decision
to my health care representative appointed under IC 16-36-1-7 or
my attorney in fact with health care powers appointed under IC 30-5-5-16.
In the absence of my ability to give directions regarding the use of
life prolonging procedures, 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 accept the
consequences of the refusal.
I understand the full import of this declaration.
The declarant has been personally known to me, and I believe
(him/her) to be of sound mind. I did not sign the declarant's signature
above for or at the direction of the declarant. I am not a parent, spouse,
or child of the declarant. I am not entitled to any part of the declarant's
estate or directly financially responsible for the declarant's medical
care. I am competent and at least eighteen (18) years of age.
Witness _______________ Date __________
Witness _______________ Date __________
[Pre-1993 Recodification Citation: 16-8-11-12(b).]