Statutory Directive to Physicians in Conformance with Washington R.C.W. 70.122.030
DIRECTIVE TO PHYSICIANS
Directive 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, and do hereby declare that:
(a) If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two physicians, and where the application of life-sustaining procedures 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death is imminent whether or not life-sustaining procedures are utilized, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally.
(b) In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this directive shall be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment and I accept the consequences from such refusal.
(c) If I have been diagnosed as pregnant and that diagnosis is known to my physician, this directive shall have no force or effect during the course of my pregnancy.
(d) I understand the full import of this declaration and I am emotionally and mentally competent to make this directive.
________________________________________
City of residence: ________________
County of residence: ______________
State of residence: _______________
Date: _____________________________
The declarer has been personally known to me and I believe him or her to be of sound mind.
Witness: __________________________________________
Witness: __________________________________________
Date: ______________________________
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