Declaration as Provided by Iowa Code 144A.3
DECLARATION OF __________________
If I should have an incurable or irreversible condition that will cause my death within a relatively short time, it is my desire that my life not be prolonged by administration of life-sustaining procedures. If my condition is terminal and I am unable to participate in decisions regarding my medical treatment, I direct my attending physician to withhold or withdraw procedures that merely prolong the dying process and are not necessary to my comfort or freedom from pain.
Signed this _______________ day of _______________, 20_____
Signature: _____________________________________________________
The Declarant is known to me and voluntarily signed this document in my presence.
Witness: __________________________________________________
Address:
Witness: __________________________________________________
Address:
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