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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withheld or withdrawn, and that I be permitted to die naturally with only the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:
___________________________________
___________________________________
___________________________________
___________________________________