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Louisiana ___________________________________________ (Witness Signature) _______________________________________________________ (Witness Signature) e) _______________________________________________________ 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. ____________al. I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration. _______________________________________________________ (Declarant's Signaturntion that this declaration shall 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 refusrformance of any medical procedure 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to give directions regarding the use of such life-sustaining procedures, it is my intend hydration, be withheld or withdrawn so that food and water can be administered invasively. I further direct that I be permitted to die naturally with only the administration of medication or the pefe-sustaining procedures, including nutrition and hydration, be withheld or withdrawn so that food and water will not be administered invasively. ___That life-sustaining procedures, except nutrition at life-sustaining procedures are utilized and where the application of life-sustaining procedure would serve only to prolong artificially the dying process, I direct (initial one only): ___That all linal and irreversible condition by two physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or noand do hereby declare: If at any time I should have an incurable injury, disease or illness, or be in a continual profound comatose state with no reasonable chance of recovery, certified to be a termimonth, year). 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 ional. 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 _______________ day of __________ (tuation. 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 discussed with a tax profess 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 fits your particular siprovided 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 advice. Laws vary from any physician or health care facility acting in good faith may rely upon the validity of the declaration. These forms are provided "as is" and no implied or express warranties have been made or are n 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 been indicated on the declaration,ds 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 a written notice of revocation i) Such revocation by any method enumerated in this Section shall become effective upon communication to the attending physician. (c) The attending physician shall record in the patient's medical recorient'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 intent to revoke the declaration. (b) By a written revocation of the declarant expressing the intent to revoke, signed and dated by the declarant. Information & Instructions ­ Page 5 (b) The attending physician shall record in the patfollowing 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. (2)(a a copy or facsimile thereof. §1299.58.4. Revocation of declaration A. A declaration may be revoked at any time by the declarant without regard to his or her mental state or competency by any of the 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 providing ofatment 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 bracelet and a fee of hentic. 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 medical tre 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 deemed autDO 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 disclosedo-not-resuscitate identification 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 phrase "n which a person, or his attorney, if authorized by the person to do so, may register the original, multiple original, or a certified copy of the declaration. (b) The secretary of state shall issue a invalid for that reason nor presumed to mean that the declarant desires the invasive administration of nutrition or hydration. D.(1)(a) The secretary of state shall establish a declaration registry ilearly provides to the contrary. (b) Any declaration executed prior to August 15, 2005, which does not contain an option to specifically initial a choice regarding nutrition and hydration shall not bent is in a continual profound comatose state shall not be invalid for that reason. Such declaration shall be applicable to any terminal and irreversible condition, as defined in this Part, unless it cections in the declaration are severable. (3)(a) Any declaration executed prior to January 1, 1992, which does not contain directions regarding life-sustaining procedures in the event that the declarae other specific directions be held to be invalid, such invalidity shall not affect other directions of the declaration which can be given effect without the invalid direction, and to this end the diruld he be diagnosed as having a terminal and irreversible condition and be comatose, incompetent, or otherwise mentally or physically incapable of communications: (included below) (2) Should any of thd not, be in the following illustrative form and may include other specific directions including but not limited to a designation of another person to make the treatment decision for the declarant shothe reasons the declarant could not make a written declaration and make the recitation a part of the patient's medical records. Information & Instructions ­ Page 4 C.(1) The declaration may, but neen, or a notation of the existence of a registered declaration, a part of the declarant's medical record. (4) If the declaration is oral or nonverbal, the physician shall promptly make a recitation of n who is so notified, 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 writtestence of the declaration. 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 physiciadeclaration has been 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 eximeans of communication 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 written declaration 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 son 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 terminal and irreversible condition. (2) Ae to be withheld or withdrawn upon his decease. 1299.58.3. Making of declaration; notification; illustrative form; registry; issuance of donot-resuscitate identification bracelets A.(1) Any adult pered 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 from whom life-sustaining procedures arical judgment, would produce death and for which the application of life-sustaining procedures would serve only to postpone the moment of death. (16) "Witness" means a competent adult who is not relat "Terminal and irreversible condition" means a continual profound comatose state with no reasonable chance of recovery or a condition caused by injury, disease, or illness which, within reasonable meduse, that has resulted in the terminal and irreversible condition as defined in Paragraph (15) of this Section, or who has violated any domestic abuse protective order affecting the other spouse. (15)ially separated from the patient, is cohabited with another person in the manner of married persons, or who has been convicted of any crime of violence as defined in R.S. 14:2(B) against the other spoions established and maintained by the secretary of state pursuant to this Part. (14) "Spouse" means a person who is legally married to the qualified patient but does not include a spouse who is judic as having a terminal and irreversible condition by two physicians who have personally examined the patient, one of whom shall be the attending physician. (13) "Registry" means a registry for declaratte Board of Medical Examiners or by the official licensing authority of another state. Information & Instructions ­ Page 3 (12) "Qualified patient" means a patient diagnosed and certified in writingl not include 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 Sta irreversible condition, including such procedures as the invasive administration of nutrition and hydration and the administration of cardiopulmonary resuscitation. A "life-sustaining procedure" shalstaining procedure" 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 andized bracelet 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-suorally, or by other means of nonverbal communication. (6) "Declarant" means a person who has executed a declaration as defined herein. (7) "Do-not-resuscitate identification bracelet" means a standardion voluntarily made by the declarant, authorizing the withholding or withdrawal of life-sustaining procedures, in accordance with the requirements of this Part. A declaration may be made in writing, nd adopted by the bureau of emergency medical services of the Department of Health and Hospitals and who is certified by the bureau. (5) "Declaration" means a witnessed document, statement, or expressdefined in R.S. 40:1231. (4) "Certified first responder" means any person who has successfully completed a training course developed and promulgated by the United States Department of Transportation ad to restore or support cardiac or respiratory function in the event of a cardiac or respiratory arrest. (3) "Certified emergency medical technician" means a certified emergency medical technician as y states otherwise: (1) "Attending physician" means the physician who has primary responsibility for the treatment and care of the patient. (2) "Cardiopulmonary resuscitation" means those measures usehe application of medical treatment or life-sustaining procedures. §1299.58.2. Definitions As used in this Part, the following words shall have the meanings ascribed to them unless the context clearln, nor shall this Part be construed to require the application of medically inappropriate treatment or life-sustaining procedures to any patient or to interfere with medical judgment with respect to ton pursuant to this Part. (3) It is the intent of the legislature that nothing in this Part shall be construed to be the exclusive means by which life-sustaining procedures may be withheld or withdraw withholding or withdrawal of medical treatment or life-sustaining procedures. (2) It is the intent of the legislature that nothing in this Part shall be construed to require the making of a declaratihis Part are permissive and voluntary. The legislature further intends that the making of a declaration pursuant to this Part merely illustrates a means of documenting a patient's decision relative todical judgment with respect to the application of medical treatment or life-sustaining procedures. Information & Instructions ­ Page 2 B. Intent. (1) The legislature intends that the provisions of tures may be withheld or withdrawn, nor shall this Part be construed to require the application of medically inappropriate treatment or life-sustaining procedures to any patient or to interfere with mee condition. (4) In furtherance of the rights of such persons, the legislature finds and declares that nothing in this Part shall be construed to be the exclusive means by which life-sustaining proced, incompetent, or otherwise physically or mentally incapable of communication, or from a minor, in the event such adult patient or minor is diagnosed and certified as having a terminal and irreversiblnd irreversible condition; and (b) The right of certain individuals to make a declaration pursuant to which lifesustaining procedures may be withheld or withdrawn from an adult patient who is comatosesician to withhold or withdraw life-sustaining procedures or designating another to make the treatment decision and make such a declaration for him, in the event he is diagnosed as having a terminal aly in decisions concerning themselves, the legislature hereby declares that the laws of the state of Louisiana shall recognize: (a) The right of such a person to make a declaration instructing his phyxistence while providing nothing medically necessary or beneficial to the person. (3) In order that the rights of such persons may be respected even after they are no longer able to participate activee artificial prolongation of life for a person diagnosed as having a terminal and irreversible condition may cause loss of individual and personal dignity and secure only a precarious and burdensome ecision to have life-sustaining procedures withheld or withdrawn in instances where such persons are diagnosed as having a terminal and irreversible condition. (2) The legislature further finds that thurpose, findings and intent A. Purpose and findings. (1) The legislature finds that all persons have the fundamental right to control the decisions relating to their own medical care, including the den Title 40 Section 1299.58.1 et. seq. of the Louisiana Statutes. For your convenience, we have included useful excerpts from the Louisiana Statutes relating to Living Wills. §1299.58.1. Legislative pInformation and Instructions Louisiana Living Will This packet includes: (1) Information and Instruction for Louisiana Living Will; and (2) Louisiana Living Will. This Louisiana Living Will is based o Louisiana