Life Sustaining Statute, Louisiana

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Statutory Declaration in Conformance with Louisiana Natural Death Act, Louisiana R. S. 40:1299.58.3

DECLARATION OF _____________________

Declaration made this __________ day of ________________ 20________.

I __________________, being of sound mind, 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 an incurable injury, disease, or illness certified to be a terminal and irreversible condition by two physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life- sustaining procedures are utilized and where the application of life-sustaining procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care.

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 from such refusal.

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

________________________________________

City of residence: ____________

Parish 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: _________________________