Life Sustaining Statute, Virginia

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Statutory Declaration in Conformance with Virginia Natural Death Act VA. Code Section 54-325.8:4

DECLARATION OF ___________________

Declaration made this __________ day of ________________ 20____. I ______________, being of sound mind, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below, do declare:

If at any time I should have a terminal condition and my attending physician has determined that there can be no recovery from such condition and my death will is imminent, 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procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me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 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 physician 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.

Signed: _______________________________________

City of residence: ______________

County of residence: ____________

State of residence: _____________

Date: _____________________

The Declarant is known to me and I believe him or her to be of sound mind.

Witness: _________________________________________________

Witness: _________________________________________________

Date: ___________________