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Indiana teen (18) years of age. Witness ________________________________________________ Date __________________ Witness ________________________________________________ Date __________________ ty and State of Residence ________________________________________________ The declarant has been personally known to me, and I believe (him/her) to be of sound mind. I am competent and at least eighical treatment and accept the consequences of the request. I understand the full import of this declaration. Signed: _______________________________________________________________________ City, Counons regarding the use of life prolonging procedures, it is my intention that this declaration be honored by my family and physician as the final expression of my legal right to request medical or surgministration of medication, and the performance of all other medical procedures necessary to extend my life, to provide comfort care, or to alleviate pain. In the absence of my ability to give directie injury, disease, or illness determined to be a terminal condition I request the use of life prolonging procedures that would extend my life. This includes appropriate nutrition and hydration, the ad____________________________________________________, being at least eighteen (18) years of age and of sound mind, willfully and voluntarily make known my desire that if at any time I have an incurabl_____________________________ Date __________________ 2 Life Prolonging Procedures DECLARATION Declaration made this _____________________ day of _____________________ (month, year). I, ____________for the declarant's medical care. I am competent and at least eighteen (18) years of age. Witness ________________________________________________ Date __________________ Witness ___________________ature above for or at the direction of the declarant. I am not a parent, spouse, or child of the declarant. I am not entitled to any part of the declarant's estate or directly financially responsible ___________________________________ City, County, and State of Residence The declarant has been personally known to me, and I believe (him/her) to be of sound mind. I did not sign the declarant's sign__________________________ I understand the full import of this declaration. Signed: _______________________________________________________________________ _______________________________________________________________________________________________________________ 1 ____________________________________________________________________________ __________________________________________________. Additional Instructions (optional): ____________________________________________________________________________ ____________________________________________________________________________ ________is my intention that this declaration 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 of the refusalntative appointed under IC 16-361-7 or my attorney in fact with health care powers under IC 30-5-5. In the absence of my ability to give directions regarding the use of life prolonging procedures, it ain life is futile or excessively burdensome to me. __________ I intentionally make no decision concerning artificially supplied nutrition and hydration, leaving the decision to my health care represeon and hydration, even if the effort to sustain life is futile or excessively burdensome to me. __________ I do not wish to receive artificially supplied nutrition and hydration, if the effort to sustn of artificially supplied nutrition and hydration. (Indicate your choice by initialing or making your mark before signing this declaration): __________ I wish to receive artificially supplied nutriti naturally with only the performance or provision of any medical procedure or medication necessary to provide me with comfort care or to alleviate pain, and, if I have so indicated below, the provisiot time; and (3) the use of life prolonging 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 dieircumstances set forth below, and I declare: If at any time my attending physician certifies in writing that: (1) I have an incurable injury, disease, or illness; (2) my death will occur within a shor____________________________, being at least eighteen (18) years of age and of sound mind, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the crs and Terms of Use found at findlegalforms.com Living Will DECLARATION Declaration made this _____________________ day of _____________________ (month, year). I, ____________________________________ith estate planning matters. Any possible 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 Disclaimeng point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealing wl effect or completeness. [_]These forms 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 startires withheld or withdrawn. [_] These forms 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 legaunless the person had actual knowledge of the revocation. (d) The revocation of a life prolonging procedures will declaration is not evidence that the declarant desires to have life prolonging procedussion of intent to revoke. (b) A revocation is effective when communicated to the attending physician. (c) No civil or criminal liability is imposed upon a person for failure to act upon a revocation ng: (1) A signed, dated writing. (2) Physical cancellation or destruction of the declaration by the declarant or another in the declarant's presence and at the declarant's direction. (3) An oral expreor life prolonging procedures will declaration Sec. 12. (a) A living will declaration or a life prolonging procedures will declaration may be revoked at any time by the declarant by any of the followiirections. The invalidity of any additional, specific directions does not affect the validity of the declaration. As added by P.L.2-1993, SEC.19. IC 16-36-4-12 - Revocation of living will declaration - Forms of declaration; requisites Sec. 9. A declaration must be substantially in the form set forth in either section 10 or 11 of this chapter, but the declaration may include additional, specific d) A life prolonging procedures will declaration under section 11 of this chapter does require the physician to use life prolonging procedures as requested. As added by P.L.2-1993, SEC.19. IC 16-36-4-9thholding, or withdrawal of life prolonging procedures under this chapter; and (2) shall be given great weight by the physician in determining the intent of the patient who is mentally incompetent. (gnder section 10 of this chapter: (1) does not require the physician to use, withhold, or withdraw life prolonging procedures but is presumptive evidence of the patient's desires concerning the use, winding physician Information & Instructions ­ Page 3 who is notified shall make the declaration or a copy of the declaration a part of the declarant's medical records. (f) A living will declaration uing the person's pregnancy. (e) The life prolonging procedures will declarant or the living will declarant shall notify the declarant's attending physician of the existence of the declaration. An atted as a personal representative or as the attorney for the estate in the declarant's will. (d) The living will declaration of a person diagnosed as pregnant by the attending physician has no effect durly responsible for the declarant's medical care. For the purposes of subdivision (3), a person is not considered to be entitled to any part of the declarant's estate solely by virtue of being nominatent's estate whether the declarant dies testate or intestate, including whether the witness could take from the declarant's estate if the declarant's will is declared invalid. (4) Be directly financialditions: (1) Be the person who signed the declaration on behalf of and at the direction of the declarant. (2) Be a parent, spouse, or child of the declarant. (3) Be entitled to any part of the declarae presence of at least two (2) competent witnesses who are at least eighteen (18) years of age. (c) A witness to a living will declaration under subsection (b)(5) may not meet any of the following contary. (2) Be in writing. (3) Be signed by the person making the declaration or by another person in the declarant's presence and at the declarant's express direction. (4) Be dated. (5) Be signed in thnder section 11 of this chapter or a living will declaration under section 10 of this chapter. (b) A declaration under section 10 or 11 of this chapter must meet the following conditions: (1) Be volun procedures will declarations; living will declarations Sec. 8. (a) A person who is of sound mind and is at least eighteen (18) years of age may execute a life prolonging procedures will declaration uth care provider for the failure to provide medical treatment to a patient who has refused the treatment in accordance with this section. As added by P.L.2-1993, SEC.19. IC 16-36-4-8 - Life prolongingcedures. (b) No health care provider is required to provide medical treatment to a patient who has refused medical treatment under this section. (c) No civil or criminal liability is imposed on a healnt; immunity from liability for failure to treat patient after refusal of treatment Sec. 7. (a) A competent person may consent to or refuse consent for medical treatment, including life prolonging proave medical or surgical means or procedures calculated to prolong the competent adult's life provided, withheld, or withdrawn. As added by P.L.2-1993, SEC.19. IC 16-36-4-7 - Consent to medical treatmege 2 As added by P.L.2-1993, SEC.19. IC 16-36-4-6 - Policy Sec. 6. A competent adult has the right to control the decisions relating to the competent adult's medical care, including the decision to h: (1) there can be no recovery; and (2) death will occur from the terminal condition within a short period of time without the provision of life prolonging procedures. Information & Instructions ­ Pa6-4-5 - Terminal condition defined Sec. 5. As used in this chapter, "terminal condition" means a condition caused by injury, disease, or illness from which, to a reasonable degree of medical certaintyent defined Sec. 4. As used in this chapter, "qualified patient" means a patient who has been certified as a qualified patient under section 13 of this chapter. As added by P.L.2-1993, SEC.19. IC 16-3 used in this chapter, "living will declarant" means a person who has executed a living will declaration under section 10 of this chapter. As added by P.L.2-1993, SEC.19. IC 16-36-4-4 - Qualified pati means a person who has executed a life prolonging procedures will declaration under section 11 of this chapter. As added by P.L.2-1993, SEC.19. IC 16-36-4-3 - Living will declarant defined Sec. 3. Asdded by P.L.2-1993, SEC.19. Amended by P.L.99-1994, SEC.1. IC 16-36-4-2 - Life prolonging procedures will declarant defined Sec. 2. As used in this chapter, "life prolonging procedures will declarant" (2) Serves to prolong the dying process. (b) The term does not include the performance or provision of any medical procedure or medication necessary to provide comfort care or to alleviate pain. As a prolonging procedure" means any medical procedure, treatment, or intervention that does the following: (1) Uses mechanical or other artificial means to sustain, restore, or supplant a vital function.he Indiana Codes relating to Living Wills. IC 16-36-4 Chapter 4. Living Wills and Life Prolonging Procedures IC 16-36-4-1 - Life prolonging procedure defined Sec. 1. (a) As used in this chapter, "lifea Living Will; (3) Life Prolonging Declaration. This Indiana Living Will is based on Indiana Code Title 16-36 Chapter 4 Section 1 et. Seq. For your convenience, we have included useful excerpts from tInformation and Instructions Indiana Living Will & Life Prolonging Declaration This package contains (1) Information and Instruction for Indiana Living Will and Life Prolonging Declaration; (2) Indian Indiana