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Louisiana ______________ (Witness Signature) _______________________________________________________ (Witness Signature) ____________________________ City, Parish and State of Residence The declarant has been personally known to me and I believe him or her to be of sound mind. _________________________________________ of this declaration and I am emotionally and mentally competent to make this declaration. _______________________________________________________ (Declarant's Signature) ___________________________l be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal. I understand the full importre deemed necessary to provide me with comfort care. In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this declaration shal the dying process, I direct that such procedures be withheld or withdrawn and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedusicians have determined that my death will occur whether or not life-sustaining procedures are utilized and where the application of life- sustaining procedure would serve only to prolong artificiallyith no reasonable chance of recovery, certified to be a terminal and irreversible condition by two physicians who have personally examined me, one of who m shall be my attending physician, and the phytificially prolonged under the circumstances set forth below and do hereby declare: If at any time I should have an incurable injury, disease or illness, or be in a continual profound comatose state w______ day of __________ (month, year). I, __________________________________________________________, being of sound mind, willfully and voluntarily make known my desire that my dying shall not be arsed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Living Will DECLARATION Declaration made this _________its your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discusadvice. 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 or signed without consulting an attorney first to make sure it fe been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax the declaration, any physician or health care facility acting in good faith ` rely upon the validity of the declaration. [_] These forms are provided "as is" and no implied or express warranties havtate shall indicate on the declaration Living Will Information & Instructions ­ Page 6 the date and time the notice of revocation was received in his office. Until the notation has been indicated onation of the revocation was received. B. A declaration registered with the secretary of state's office may be revoked by the filing of a written notice of revocation in that office. The secretary of snumerated in this Section shall become effective upon communication to the attending physician. (c) The attending physician shall record in the patient's medical records the time and date when notific date when notification of the written revocation was received. (3) (a) By an oral or nonverbal expression by the declarant of the intent to revoke the declaration. (b) Such revocation by any method e) (a) By a written revocation of the declarant expressing the intent to revoke, signed and dated by the declarant. (b) The attending physician shall record in the patient's medical record the time andhe following methods: (1) By being cancelled, defaced, obliterated, burned, torn, or otherwise destroyed by the declarant or by some person in the presence of and at the direction of the declarant. (2g of a copy or facsimile thereof. §1299.58.4. Revocation of declaration A. A declaration may be revoked at any time by the declarant without rega` to his or her mental state or competency by any of t of five dollars for filing a notice of revocation. No charge shall be made for the furnishing of information concerning the existence of a declaration, the disclosure of its contents, or the providinl treatment or life-sustaining procedures. (3) The secretary of state may charge a fee of twenty dollars for registering a declaration and issuing a do- not-resuscitate identification brace` and a feed authentic. However, nothing herein requires a physician or health care facility to confirm the existence of such declaration or obtain a copy thereof prior to the withholding or withdrawal of medicaclose the contents thereof for any patient believed to be a resident of Louisiana. A copy of the declaration or a facsimile thereof transmitted from the office of the secretary of state shall be deemease "DO NOT RESUSCITATE". (2) Any attending physician or health care facility may, orally or in writing, request the secretary of state to confirm immediately the existence of a declaration and to disa do- not-resuscitate id entification bracelet to qualified patients listed in the registry. The do- not-resuscitate identification bracelet must include the patient's name, date of birth, and the phr by the person to do so, may register the original, multiple original, or a certified copy of the declaration. Living Will Information & Instructions ­ Page 5 (b) The secretary of state shall issue ondition, as defined in this Part, unless it clearly provides to the contrary. D (1) (a) The secretary of state shall establish a declaration registry in which a person, or his attorney, if authorizedaining procedures in the event that the declarant is in a continual profound comatose state shall not be invalid for th` reason. Such declaration shall be applicable to any terminal and irreversible chout the invalid direction, and to this end the directions in t` declaration are severable. (3) Any declaration executed prior to January 1, 1992, which does not contain directions regarding life sustications: (form included below) (2) Should any of the other specific directions be held to be invalid, such invalidity shall not affect other directions of the declaration which can ` given effect witke the treatment decision for the declarant should he be diagnosed as having a terminal and irreversible condition and be comatose, incompetent, or otherwise mentally or physically incapable of communal records. C. (1) The declaration may, but need not, be in the following illustrative form and may include other specific directions including but not limited to a designation of another person to madeclaration is oral or nonverbal, the physician shall promptly make a recitation of the reasons the declarant could not make a written declaration and make the recitation a part of the patient's medicregistered shall promptly make the declaration or a copy of the declaration, if written, or a notation of the existence of a registered declaration, a part of the declaran` medical record. (4) If the registry to determine the existence of any such declaration. (3) Any attending physician who is so notified, or who determines directly or is advised by the health care facility that a declaration is ically incapable of communication, any other person may notify the physician of the existence of the declaration. In addition, the attending physician or health care facility may directly contact the shall be the responsibility of the declarant to notify his attending physician that a declaration has been made. (2) In the event the declarant is comatose, incompetent, or otherwise mentally or physeclaration may be made by an adult in the presence of two witnesses by any nonwritten means of communication at any time subsequent to the diagnosis of a terminal and irreversible condition. B. (1) Ital and irreversible condition. (2) A written declaration shall be signed by the declarant in the presence of two witnesses. Living Will Information & Instructions ­ Page 4 (3) An oral or nonverbal dation bracelets A. (1) Any adult person may, at any time, make a written declaration directing the withholding or withdrawal of life-sustaining procedures in the event such person should have a termin whom life-sustaining procedures are to be withheld or withdrawn upon his decease. 1299.58.3. Making of declaration; notification; illustrative form; registry; issuance of donot-resuscitate identific a competent adult who is not related to the declarant or qualified patient, whichever is applicable, by blood or marriage and who would not be entitled to any portion of the estate of the person fromllness which, within reasonable medical judgment, would produce death and for which the application of life-sustaining procedures would serve only to postpone the moment of death. (15) "Witness" meansf state pursuant to this Part. (14) "Terminal and irreversible condition" means a continual profound comatose state with no reasonable chance of recovery or a condition caused by injury, disease, or i two physicians who have personally examined the patient, one of whom shall be the attending physic ian. (13) "Registry" means a registry for declarations established and maintained by the secretary oedical Examiners or by the official licensing authority of another state. (12) "Qualified patient" means a patient diagnosed and certified in writing as having a terminal and irreversible condition by any measure deemed necessary to provide comfort care. (10) "Minor" means a person under eighteen years of age. (11) "Physician" means a physician or surgeon licensed by the Louisiana State Board of M condition, including such procedures as the invasive administration of nutrition and hydration and the administration of cardiopulmonary resuscitation. A "life-sustaining procedure" shall not includeedure" means any medical procedure or intervention which, within reasonable medical judgment, would serve only to prolong the dying process for a person diagnosed as having a terminal and irreversible as described in R.S. 40:1299.58.3(D)(1)(b). (8) "Health care provider" means any health maintenance organization, home health agency, hospice, hospital, or nursing facility. (9) "Life-sustaining procarant" means a person who has executed a declaration as defined herein. Living Will Information & Instructions ­ Page 3 (7) "Do-not-resuscitate identification bracelet" means a standardized braceleting or withdrawal of life-sustaining procedures, in accordance with the requirements of this Part. A declaration may be made in writing, orally, or by other means of nonverbal communication. (6) "Declepartment of Health and Hospitals and who is certified by the bureau. (5) "Declaration" means a witnessed document, statement, or expression voluntarily made by the declarant, authorizing the withholdany person who has successfully completed a training course developed and promulgated by the United States Department of Transportation and adopted by the bureau of emergency medical services of the Devent of a cardiac or respiratory arrest. (3) "Certified emergency medical technician" means a certified emergency medical technician as defined in R.S. 40:1231. (4) "Certified first responder" means an who has primary responsibility for the treatment and care of the patient. (2) "Cardiopulmonary resuscitation" means those measures used to restore or support cardiac or respiratory function in the es. §1299.58.2. Definitions As used in this Part, the following words shall have the meanings ascribed to them unless the context clearly states otherwise: (1) "Attending physician" means the physici` of medically inappropriate treatment or lifesustaining procedures to any patie` or to interfere with medical judgment with respect to the application of medical treatment or life-sustaining procedurlature that nothing in this Part shall be construed to be the exclusive means by which life-sustaining procedures may be withheld or withdrawn, nor shall this Part be construed to require the applicattaining procedures. (2) It is the intent of the legislature that nothing in this Part shall be construed to require the making of a declaration pursuant to this Part. (3) It is the intent of the legisther intends that the making ` a declaration pursuant to this Part merely illustrates a means of documenting a patient's decision relative to withholding or withdrawal of medical treatment or life-susrespect to the application of medical treatment or life-sustaining procedures. B. Intent. (1) The legislature intends that the provisions of this Part are permissive and voluntary. The legislature furo require the application of medically inappropriate treatme` or life-sustaining procedures to any patient or to interfere Living Will Information & Instructions ­ Page 2 with medical judgment with legislature finds and declares that nothing in this Part shall be construed to be the exclusive m` by which life-sustaining procedures may be withheld or withdrawn, nor shall this Part be construed tmunication, or from a minor, in the event such adult patient or minor is diagnosed and certified as having a terminal and irreversible conditions, (4) In furtherance of the rights of such persons, theto make a declaration pursuant to which life-sustaining procedures may be withheld or withdrawn from an adult patient who is comatose, incompetent, or otherwise physically or mentally incapable of comnating another to make the treatment decision and make such a declaration for him, in ` event he is diagnosed as having a terminal and irreversible condition; and (b) The right of certain individuals ares that the laws of the state of Louisiana shall recognize: (a) The right of such a person to make a declaration instructing his physician to withhold or withdraw life-sustaining procedures or desig to the person. (3) In order that the rights of such persons may be respected even after they are no longer able to participate actively in decisions concerning themselves, the legislature hereby decl a terminal and irreversible condition may cause loss of individual and personal dignity and secure only a precarious and burdensome existence while providing nothing medically necessary or beneficialinstances where such persons are diagnosed as having a terminal and irreversible condition. (2) The le gislature further finds that the artificial prolongation of life for a person diagnosed as havingslature finds that all persons have the fundamental right to control the decisions relating to their own medical ca` including the decision to have life-sustaining procedures withheld or withdrawn in For your convenience, we have included useful excerpts from the Louisiana Statutes relating to Living Wills. §1299.58.1. Legislative purpose, findings and intent A. Purpose and findings. (1) The legige contains (1) Information and Instruction for Louisiana Living Will; (2) Louisiana Living Will. This Louisiana Living Will is based on Title 40 Section 1299.58.3 et. Seq. of the Louisiana Statutes. und mind. Witness ______________________________________________________ Witness ______________________________________________________ Information and Instructions Louisiana Living Will This packalaration. Signed ___________________________________________ City, Parish and State of Residence ____________________ The declarant has been personally known to me and I believe him or her to be of soclaration will nevertheless be given effect should the above-discussed circumstance arise. I understand the full import of this declaration and I am emotionally and mentally competent to make this decabove, and I trust his/her judgment on my behalf. I understand that if I have not filled in any name in this clause or if the agent I have chosen is unavailable or unwilling to act on my behalf, my demy successor attorney-in- fact, unless the attending physician determines that I have decisional capacity. I have discussed my desires concerning terminal care with my agent and alternate agent named ability or mental incompetence. The determination of whether I can make my own medical decisions is to be made by my attorney- in- fact, or if he or she is unable, unwilling or unavailable to act, by _____________________ (telephone number of successor attorney- in-fact) This power of attorney becomes effective when I can no longer make my own medical decisions, and is not affected by physical dis_______________________________________________ (name of successor attorney- in-fact) _______________________________________________ (address of successor attorney- in- fact) ________________________petent or otherwise mentally or physically incapable of communication. In the event the person I appoint is unable, unwilling or unavailable to act as my attorney- in- fact, I hereby appoint: ________including decisions to withhold or withdraw any form of life-sustaining procedure on my behalf should I be (1) diagnosed as suffering from a terminal and irreversible condition and (2) comatose, incom (address of attorney- infact) ______________________________________________________ (telephone number of attorney- in- fact) as my attorney- in- fact to make all medical treatment decisions for me, ______, being of sound mind, willfully and voluntarily appoint: ___________________________________________________ (name of attorney- in-fact) ________________________________________________________f Use found at findlegalforms.com -4- Power of Attorney for Health Care Declaration made this _______________ day of __________ (month, year). I, ____________________________________________________r party. Any -3- 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 Disclaimers and Terms o using or signing this document you should have an attorney review it to make sure it fits your particular situatio n. You should also consult an attorney whenever a document is negotiated with anothegal 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 without consulting with an attorney first. Before 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 are not intended and are not a substitute for leen indicated on the declaration, any physician or health care facility acting in good faith ` rely upon the validity of the declaration. [_] These forms are provided "as is" and no implied or expressa written notice of revocation in that office. The secretary of state shall indicate on the declaration the date and time the notice of revocation was received in his office. Until the notation has bed in the patient's medical records the time and date when notification of the revocation was received. B. A declaration registered with the secretary of state's office may be revoked by the filing of nt to revoke the declaration. (b) Such revocation by any method enumerated in this Section shall become effective upon communication to the attending physician. (c) The attending physician shall recorysician shall record in the patient's medical record the time and date when notification of the written revocation was received. (3) (a) By an oral or nonverbal expression by the declarant of the interson in the presence of and at the direction of the declarant. (2) (a) By a written revocation of the declarant expressing the intent to revoke, signed and dated by the declarant. (b) The attending phthout regard to his or her mental state or competency by any of the following methods: (1) By being cancelled, defaced, obliterated, burned, torn, or otherwise destroyed by the declarant or by some pef a declaration, the disclosure of its contents, or the providing of a copy or facsimile thereof. §1299.58.4. Revocation of declaration A. A declaration may be revoked at any time by the declarant wisuing a do-not-resuscitate identification brace` and a fee of five dollars for filing a -2- notice of revocation. No charge shall be made for the furnishing of information concerning the existence opy thereof prior to the withholding or withdrawal of medical treatment or life-sustaining procedures. (3) The secretary of state may charge a fee of twenty dollars for registering a declaration and ised from the office of the secretary of state shall be deemed authentic. However, nothing herein requires a physician or health care facility to confirm the existence of such declaration or obtain a confirm immediately the existence of a declaration and to disclose the contents thereof for any patient believed to be a resident of Louisiana. A copy of the declaration or a facsimile thereof transmittmust include the patient's name, date of birth, and the phrase "DO NOT RESUSCITATE". (2) Any attending physician or health care facility may, orally or in writing, request the secretary of state to co of the declaration. (b) The secretary of state shall issue a do- not-resuscitate identification bracelet to qualified patients listed in the registry. The do- not-resuscitate identification bracelet he secretary of state shall establish a declaration registry in which a person, or his attorney, if authorized by the person to do so, may register the original, multiple original, or a certified copyhall not be invalid for that reason. Such declaration shall be applicable to any terminal and irreversible condition, as defined in this Part, unless it clearly provides to the contrary. D. (1) (a) T3) Any declaration executed prior to January 1, 1992, which does not contain directions regarding life sustaining procedures in the event that the declarant is in a continual profound comatose state s invalid, such invalidity shall not affect other directions of the declaration which can ` given effect without the invalid direction, and to this end the directions in t` declaration are severable. (ersible condition and be comatose, incompetent, or otherwise mentally or physically incapable of communications (see form enclosed below): (2) Should any of the other specific directions be held to beay include other specific directions including but not limited to a designation of another person to make the treatment decision for the declarant should he be diagnosed as having a terminal and irrevhe declarant could not make a written declaration and make the recitation a part of the patient's medical records. C. (1) The declaration may, but need not, be in the following illustrative form and m the existence of a registered declaration, a part of the declarant's medical record. -1- (4) If the declaration is oral or nonverbal, the physician shall promptly make a recitation of the reasons ted, or who determines directly or is advised by the health care facility that a declaration is registered shall promptly make the declaration or a copy of the declaration, if written, or a notation ofaration. In addition, the attending physician or health care facility may directly contact the registry to determine the existence of any such declaration. (3) Any attending physician who is so notifien made. (2) In the event the declarant is comatose, incompetent, or otherwise mentally or physically incapable of communication, any other person may notify the physician of the existence of the declion at any time subsequent to the diagnosis of a terminal and irreversible condition. B. (1) It shall be the responsibility of the declarant to notify his attending physician that a declaration has ben shall be signed by the declarant in the presence of two witnesses. (3) An oral or nonverbal declaration may be made by an adult in the presence of two witnesses by any nonwritten means of communicate, make a written declaration directing the withholding or withdrawal of life-sustaining procedures in the event such person should have a terminal and irreversible condition. (2) A written declaratioorney for Health Care Form. 1299.58.3. Making of declaration; notification; illustrative form; registry; issuance of donot-resuscitate identification bracelets A. (1) Any adult person may, at any timAttorney for Health Care is based on Title 40 Section 1299.58.3 et. Seq. of the Louisiana Statutes. The following are useful excerpts from the Louisiana Statutes relating to the Louisiana Power of Attey for Health Care This package contains (1) Information and Instruction for Louisiana Power of Attorney for Health Care; (2) Louisiana Power of Attorney for Health Care Form. This Louisiana Power of ssed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Information and Instructions Louisiana Power of Attornfits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discu 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 or signed without consulting an attorney first to make sure it e been made or are provided as to their suitability for any specific purpose or as to their legal effect or comp leteness. [_]These forms are not intended and are not a substitute for legal and/or taxce Health Care Directive. The first form is the Power of Attorney for Health Care and the second form is the Living Will. [_] These forms are provided "as is" and no implied or express warranties havLouisiana Advance Health Care Directive This package contains both a Louisiana Power of Attorney for Health Care and a Louisiana Living Will. Together these forms are also sometimes known as an Advan Louisiana