§ 16-36-4-11 — Form of life prolonging procedures will declaration

The following is the life prolonging
procedures will declaration form:
LIFE PROLONGING PROCEDURES 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 desire that if at any
time I have an incurable injury, disease, or illness determined to be a
terminal condition I request the use of life prolonging procedures that
would extend my life. This includes appropriate nutrition and
hydration, the administration of medication, and the performance of all
other medical procedures necessary to extend my life, to provide
comfort care, or to alleviate pain.
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 request medical or surgical treatment and accept the
consequences of the request.
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 am competent and at least eighteen
(18) years of age.
Witness ______________ Date ________
Witness ______________ Date ________
[Pre-1993 Recodification Citation: 16-8-11-12(c).]

Legislative History

As added by P.L.2-1993, SEC.19.