Life Sustaining Statute, Indiana

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Statutory Declaration in Conformance with Indiana Living Will and Life-Prolonging Procedures Act, Indiana Code 16-8-11-12

LIVING WILL DECLARATION OF ________________

Declaration made this __________ day of _________________ 20________.

I, _____________, being at least eighteen (18) years old 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 I should have an incurable and irreversible injury, disease, or illness certified in writing to be a terminal condition by my attending physician, and my attending physician has determined that my death will occur in a short period of time, and 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procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the provision of appropriate nutrition and hydration and the administration of medication and the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 prolonging delaying procedures, it is my intention that this declaration shall 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.

________________________________________

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. 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 Declarant’s medical care. I am competent and at least eighteen (18) years old.

Witness _________________________________________________

Witness _________________________________________________

Date: _______________________