Life Sustaining Statute, Idaho

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Directive to Physicians as Provided by Idaho Natural Death Act, Idaho Code Section 39-4504

DIRECTIVE TO PHYSICIANS

Directive made this _________________ day of ___________. I _____________________, being of sound mind, willfully and voluntarily make known my desire that my life shall not be artificially prolonged under the circumstances below:

1. In the absence of my ability to give directions regarding the use of artificial life-sustaining procedures as result of the disease process of my terminal condition, it is my intention that such artificial life-sustaining procedures should not be used when they would serve only to artificially prolong the moment of my death and where my physician determines that my death is imminent whether or not life-sustaining procedures are utilized.

2. I have been diagnosed and notified that I have a terminal condition known as _____________ by ___________ whose address is ___________________, and whose telephone number is ____________.

3. This directive shall have no force and effect five years from the date filled in above.

4. I understand the full import of this directive and I am emotionally and mentally competent to make this directive.

Signed _________________________________________________

STATE OF IDAHO

COUNTY OF _________

We, _________________________, _______________________, and _____________________________, the qualified patient and the witnesses respectively, who names are signed to the attached and foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the qualified patient signed and executed the directive and the he signed willingly and he executed it as his free and voluntary act for the purposes therein expressed; and that each of the witnesses, in the presence and hearing of the qualified patient signed the directive as witness and that to the best of his knowledge the qualified patient was at the time 18 or more years of age, of sound mind and under no constraint or undue influence. We the undersigned witnesses further declare that we are not related to the qualified patient by blood or marriage; that we are not entitled to any portion of the estate of the qualified patient upon his decease under any will or codicil thereto presently existing or by operation of law then existing; that we are not the attending physician, an employee of the attending physician or a health facility in which the qualified patient is a patient, and that we are not a person who has a claim against any portion of the estate of the qualified patient upon his decease at the present time.

________________________________________________

Qualified Patient

Subscribed, sworn to and acknowledged before me by _______________________, the qualified patient, and subscribed and sworn to before me by _______________________ and _____________________, witnesses, this __________ day of _________________, 20_______.

________________________________________________

Notary Public for the State of Idaho

Residing at __________________________, Idaho