Statutory Declaration in Conformance with Florida Life Prolonging Procedure Act, F.S. 765.05
DECLARATION OF ________________________
Declaration made this __________ day of _____________ 20________. I ___________ willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, do hereby declare:
If at any time I should have a terminal condition, and if my attending physician has determined that there can be no recovery from such condition and my death is imminent, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain.
In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this declaration shall be honored by my family and physicians as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences for such refusal.
If I have been diagnosed as pregnant and that diagnosis is known to my physician, this declaration shall have no force or effect during the course of my pregnancy.
I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration.
_______________________________________
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City of residence: _____________________
County of residence: ___________________
State of residence: ____________________
Date: ________________________
The Declarant has been personally known to me and I believe him or her to be of sound mind.
Witness: ___________________________________________
Witness: ___________________________________________
Date: ___________________________
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