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DECLARATION

WYOMING

 

NOTICE:  This document has significant medical, legal and possible ethical implications and effects.  Before you sign this document, you should become completely familiar with these implications and effects.  The operation, effects, and implications of this document may be discussed with a physician, a lawyer and a clergyman of your choice.

 

Declaration made this _____ day of _______________, 19___.  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 other illness certified to be a terminal condition or a permanently unconscious condition (irreversible coma) by two (2) physicians who have personally examined me, one (1) 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, or that I will remain in a permanently unconscious condition (irreversible coma) 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procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me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.

 

If I have a condition stated above, it is my preference TO RECEIVE artificially administered nutrition and hydration (food and fluids).

 

If I have been diagnosed as pregnant and that diagnosis is known to my physician, this document shall have no force or effect during the course of my pregnancy.  However, if at any point it is determined that it is not possible that the fetus could develop to the point of live birth with continued application of life-sustaining treatment, it is my preference that this document be given effect at that point.  If life-sustaining treatment will be physically harmful or unreasonably painful to me in a manner that cannot be alleviated by medication, I request that my desire for personal physical comfort be given consideration in determining whether this document shall be effective if I am pregnant.

 

If, in spite of this declaration, I am comatose or otherwise unable to make treatment decisions for myself, I hereby designate _________________________, currently residing at _________________________, _________________________, ___ __________, to make treatment decisions for me.

 

If any provision in this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.

 

In the absence of my ability to give directions regarding the use of life-sustaining procedures, it is my intention that this declaration shall be honored by my family and physician(s) and agent as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from this refusal.  I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration.

 

 

________________________________________

Signature

 

Declarant Name:                    _________________________

Declarant Address:                 _________________________

                                                _________________________ County

                                                Wyoming

 

 

 

 

The Declarant has been personally known to me and I believe the Declarant to be of sound mind.  I did not sign the Declarant's signature above or at the direction of the Declarant.  I am not related to the Declarant by blood or marriage, entitled to any portion of the estate of the Declarant according to the laws of Intestate Succession or under any Will or Codicil of the Declarant, or directly financially responsible for the Declarant's medical care.

 

 

 

Witness Signature:_________________________________________

 

Witness Name:                  _________________________

 

Witness Address:               ___________________________________

                                           ___________________________________

                                           ___________________________________

                                           ___________________________________

 

 

 

 

Witness Signature:_________________________________________

 

Witness Name:                  _________________________

 

Witness Address:               ___________________________________

                                           ___________________________________

                                           ___________________________________

                                           ___________________________________