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Idaho _______________________ Address: __________________________________________________________________ 2 ss: __________________________________________________________________ Witness Signature: __________________________________________________________ Name: _____________________________________________nd I believe him/her to be of sound mind. Witness Signature: __________________________________________________________ Name: ____________________________________________________________________ AddreAddress: __________________________________________________________________ ______________________________________ Zip Code: ___________________________ The declarant has been known to me personally a_____________________________________________ Declarant's Signature: _______________________________________________________ Name: ____________________________________________________________________ ns (optional): ____________________________________________________________________________ ____________________________________________________________________________ _______________________________e a medical doctor, my spouse, a relative, friend or any other person shall be held responsible in any way, legally, professionally or socially, for complying with my directions. Additional Instructiothe full importance of this directive and am emotionally and mentally competent to make this directive. No participant in the making of this directive or in its being carried into effect, whether it bes of such refusal. 4. If I have been diagnosed as pregnant and that diagnosis is known to any interested person, this directive shall have no force during the course of my pregnancy. 5. I understand my intention that this directive shall be honored by my family and physicians as the final expression of my legal right to refuse or accept medical and surgical treatment, and I accept the consequenced a Durable Power of Attorney for health care decisions on this date. 1 3. In the absence of my ability to give further directions regarding my treatment, including life-sustaining procedures, it isamily, relatives, friends, physicians and lawyer as the final expression of my legal right to refuse medical or surgical treatment; and I accept the consequences of such a decision. I have duly execut___________ (address) as my attorney-in-fact/proxy for the making of decisions relating to my health care in my place; and it is my intention that this appointment shall be honored by him/her, by my f my ability to give directions regarding the use of life-sustaining procedures, I hereby appoint ___________________________________________ (name) currently residing at ______________________________ocedures shall serve only to prolong artificially my life, I direct such procedures be withheld or withdrawn including withdrawal of the administration of nutrition and hydration. 2. In the absence ofd or withdrawn except for the administration of nutrition and hydration. If at any time I should become unable to communicate my instructions and where the application of artificial life-sustaining prld become unable to communicate my instructions and where the application of artificial life-sustaining procedures shall serve only to prolong artificially my life, I direct such procedures be withhel me. Nutrition and hydration shall not be withheld or withdrawn from me if I would die from malnutrition or dehydration rather than from my injury, disease, illness or condition. If at any time I shouy instructions, then I direct that all medical treatment, care, and nutrition and hydration necessary to restore my health, sustain my life, and to abolish or alleviate pain or distress be provided totted to die naturally, and that I receive any medical treatment or care that may be required to keep me free of pain or distress. "Check One Box" If at any time I should become unable to communicate mt lifesustaining procedures are utilized, or I have been diagnosed as being in a persistent vegetative state, I direct that the following marked expression of my intent be followed and that I be permime, and where the application of life-sustaining procedures of any kind would serve only to prolong artificially my life, and where a medical doctor determines that my death is imminent, whether or nocumstances set forth below, do hereby declare: 1. If at any time I should have an incurable injury, disease, illness or condition certified to be terminal by two (2) medical doctors who have examined day of _________, 20___ I, ________________________________. (name), being of sound mind, willfully, and voluntarily make known my desire that my life shall not be prolonged artificially under the cirrms.com Living Will A Directive to Withhold or to Provide Treatment To my family, my relatives, my friends, my physicians, my employers, and all others whom it may concern: Directive made this _____ e tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalfoor signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possibl are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used ms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms or civil liability on the part of any person for failure to act upon a revocation of a directive made pursuant to this section unless that person has actual knowledge of the revocation. [_] These for written, signed, revocation of the maker thereof expressing his intent to revoke. (c) By a verbal expression by the maker thereof of his intent to revoke the directive. (2) There shall be no criminal any of the following methods: (a) By being cancelled, defaced, obliterated or burned, torn or otherwise destroyed by the maker thereof or by some person in his presence and by his direction. (b) By aed herein are the only effective means of such communication. 39-4506. REVOCATION. (1) A directive may be revoked at any time by the maker thereof, without regard to his mental state or competence, by able to communicate with the physician. It is the intent of the legislature to establish an effective means for such communication. It is not the intent of the legislature that the procedures describhall recognize the right of a competent person to have his wishes for medical treatment and for the withdrawal of artificial life sustaining procedures carried out even though that person is no longerhe patient's inability to communicate with the physician. In recognition of the dignity and privacy which patients have a right to expect, the legislature hereby declares that the laws of this state sts are sometimes unable to express their desire to withhold or withdraw such artificial life prolongation procedures which provide nothing medically necessary or beneficial to the patient because of t or withdrawn. The legislature further finds that modern medical technology has made possible the artificial prolongation of human life beyond natural limits. The legislature further finds that patienthe fundamental right to control the decisions relating to the rendering of their medical care, Information & Instructions ­ Page 2 including the decision to have life sustaining procedures withheldble power of attorney to the extent that it authorizes an attorney in fact to make health care decisions for the principal. 39-4502. STATEMENT OF POLICY. The legislature finds that adult persons have ocedures shall not include the administration of medication or the performance of any medical procedure deemed necessary to alleviate pain. (4) "Durable power of attorney for health care" means a dura judgment of the attending physician, death is imminent whether or not such procedures are utilized, or the patient is diagnosed as being in a persistent vegetative state. Artificial lifesustaining predure or intervention which utilizes mechanical means to sustain or supplant a vital function which when applied to a qualified patient, would serve only to artificially prolong life and where, in thethe patient. (2) "Competent person" means any emancipated minor or any person eighteen (18) or more years of age who is of sound mind. (3) "Artificial life-sustaining procedure" means any medical procs chapter: (1) "Attending physician" means the physician licensed by the state board of medicine, selected by, or assigned to, the patient who has primary responsibility for the treatment and care of t forth in this section. 39-4501. SHORT TITLE. This act shall be known and may be cited as the "Natural Death Act." 39-4503. DEFINITIONS. The following definitions shall govern the construction of thiRAL DEATH ACT) 39-4504. LIVING WILL. Any competent person may execute a document known as a "living will." Such document shall be in the following form or in another form that contains the elements se5 Section 39-4504 et. Seq. of the Idaho Statutes. For your convenience, we have included useful excerpts from the Idaho Statutes relating to Living Wills. TITLE 39 (HEALTH AND SAFETY) CHAPTER 45 (NATUInformation and Instructions Idaho Living Will This package contains (1) Information and Instruction for Idaho Living Will; (2) Idaho Living Will. This Idaho Living Will is based on Title 39 Chapter 4 Idaho