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North Dakota ___ Address: ______________________________________ 4 ox: [_____]. I certify that the information in (1) through (3) is true and correct _____________________________________________ (Signature of Witness Two) Print Name: ________________________________ least eighteen years of age. (3) If I am a health care or long-term care provider or an employee of a health care or long-term care provider giving direct care to the declarant, I must initial this bme of declarant) acknowledged the declarant's signature on this document or acknowledged that the declarant directed the person signing this document to sign on the declarant's behalf. 3 (2) I am atSignature of Witness One) Print Name: ___________________________________ Address: ______________________________________ Witness Two: (1) In my presence on _________ (date), _____________________ (nae provider giving direct care to the declarant, I must initial this box: [_____]. I certify that the information in (1) through (3) is true and correct. _____________________________________________ ( signing this document to sign on the declarant's behalf. (2) I am at least eighteen years of age. (3) If I am a health care or long-term care provider or an employee of a health care or long-term carss One: (1) In my presence on _________ (date), _____________________ (name of declarant) acknowledged the declarant's signature on this document or acknowledged that the declarant directed the persong this document to sign on the declarant's behalf. ______________________________ (Signature of Notary Public) My commission expires __________________________ , 20__. i. Option 2: Two Witnesses Witneon _______________ (date), ____________________________________(name of declarant) acknowledged the declarant's signature on this document or acknowledged that the declarant directed the person signin____________________________________________________________ (Declarant's Signature) City, County, and State of Residence _______________________________ 2 h. Option 1: Notary Public In my presence y signing this declaration, I am at least eighteen years of age, and I am emotionally and mentally competent to make this declaration. g. I understand that I may revoke this declaration at any time. _gnosed as pregnant and that diagnosis is known to my physician, this declaration is not effective during the course of my pregnancy. f. I understand the importance of this declaration, I am voluntarilsician determines that I cannot physically assimilate nutrition or hydration or that nutrition or hydration would be physically harmful or would cause unreasonable physical pain. e. If I have been dia the administration of nutrition and hydration, I understand that if I make no statement about nutrition or hydration, my attending physician may withhold or withdraw nutrition or hydration if the phyor hydration would only prolong the process of my dying. (3) [________] I do not wish to receive hydration. (4) [________] I make no statement concerning the administration of hydration. d. Concerningwish to receive hydration. (2) [________] I wish to receive hydration unless I cannot physically assimilate hydration, hydration would be physically harmful or would cause unreasonable physical pain, t concerning the administration of nutrition. c. I have made the following decision concerning the administration of hydration when my death is imminent (initial only one statement): (1) [________] I sically harmful or would cause unreasonable physical pain, or nutrition would only prolong the process of my dying. (3) [________] I do not wish to receive nutrition. (4) [________] I make no statemenmminent (initial only one statement): (1) [________] I wish to receive nutrition. 1 (2) [________] I wish to receive nutrition unless I cannot physically assimilate nutrition, nutrition would be phycal treatment be provided. (3) [________] I make no statement concerning life-prolonging treatment. b. I have made the following decision concerning the administration of nutrition when my death is ig treatment, will result in my imminent death. It is my intention that this declaration be honored by my family and physicians as the final expression of my legal right to direct that medical or surgiment, which could extend my life, be used if two physicians certify that I am in a terminal condition that is an incurable or irreversible condition which, without the administration of life-prolonginthe final expression of my legal right to refuse medical or surgical treatment and that they accept the consequences of that refusal, which is death. (2) [________] I direct that life-prolonging treatfe-prolonging treatment would serve only to artificially prolong the process of my dying; and (c) I am not pregnant. It is my intention that this declaration be honored by my family and physicians as I am in a terminal condition that is an incurable or irreversible condition which, without the administration of life-prolonging treatment, will result in my imminent death; (b) The application of li-prolonging treatment (initial 1, 2, or 3): (1) [________] I direct that life-prolonging treatment be withheld or withdrawn and that I be permitted to die naturally if two physicians certify that: (a)the Disclaimers and Terms of Use found at findlegalforms.com Living Will DECLARATION I declare on ____________________________(month, day, year): a. I have made the following decision concerning lifehen dealing with 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 y 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 situation. Advice from a local attorney is always recommended wto their legal 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 onlpart of the declarant's medical record. [_] 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 ocation is effective upon communication to the attending physician or other health care provider by the declarant. 3. The attending physician or other health care provider shall make the revocation a Physical cancellation or destruction of the declaration by the declarant or another in the declarant's presence and at the declarant's direction; or c. An oral expression of intent to revoke. 2. A rev3-06.4-05. Revocation of declaration. 1. A declaration may be revoked at any time and in any manner by the declarant, provided the declarant is competent, including by: a. A signed, dated writing; b. eight by the physician in determining the intent of the incompetent declarant. A declaration made under section 23-06.4-03 does not apply to emergency treatment performed in a prehospital situation. 2o use, withhold, or withdraw life-prolonging treatment but is presumptive evidence of the declarant's desires concerning the use, withholding, or withdrawal of such treatment and must be given great w to be in a terminal condition and no longer able to make decisions regarding administration of life-prolonging treatment. A declaration made under section 23-06.4-03 does not obligate the physician t6.4-04. When declaration operative. A declaration becomes operative when it is communicated to the attending physician, and the declarant is determined by the attending physician and another physicianof the declaration shall make it a part of the declarant's medical record and, if unwilling to comply with the declaration, promptly so advise the declarant. Information & Instructions ­ Page 3 23-0is chapter. The invalidity of any additional specific directives does not affect the validity of the declaration. (see form below) 3. A physician or other health care provider who is furnished a copy m is a preferred form, but not a required form, by which a person may execute a declaration. The declaration may include additional specific directives. Another form may be used if it complies with tharant at the time of the execution of the declaration; d. Directly financially responsible for the declarant's medical care; or e. Attending physicians of the declarant. 2. The following statutory fornt under any will of the declarant or codicil to the will or deed, existing by operation of law or otherwise, at the time of the declaration; c. Claimants against any portion of the estate of the declf execution. The notary public or any witness may not be: a. The declarant's spouse or related to the declarant by blood, marriage, or adoption; b. Entitled to any portion of the estate of the declarae execution of the declaration must not be a health care provider providing direct care to the declarant or an employee of the health care provider providing direct care to the declarant on the date ore at least eighteen years of age. A person notarizing the declaration may be an employee of a health care or long-term care provider providing direct care to the declarant. At least one witness to thon, and contain verification of the declarant's signature or the signature of the person directed by the declarant to sign on behalf of the declarant, either by notary public or by two witnesses who adeclaration governing the use, withholding, or withdrawal of life-prolonging treatment, nutrition, and hydration. The declaration must be signed by the declarant, or another at the declarant's directihat will not result in imminent death. 23-06.4-03. Declaration relating to use of life-prolonging treatment. 1. An individual of sound mind and eighteen or more years of age may execute at any time a n, in imminent death. The term does not include any form of senility, Alzheimer's disease, mental retardation, mental illness, or chronic mental or physical impairment, including comatose conditions tnal condition. 7. "Terminal condition" means an incurable or irreversible condition that, without the administration of life-prolonging treatment, will result, in the opinion of the attending physiciatient eighteen or more years of age who has executed a declaration and who has been determined by the attending physician and another physician who has personally examined the patient to be in a termiprehospital situation. 5. "Physician" means an individual licensed to practice medicine in this state pursuant to chapter 43-17. Information & Instructions ­ Page 2 6. "Qualified patient" means a pae nutrition and hydration or the performance of any medical procedure necessary to provide comfort care or alleviate pain; or medical procedures, treatment, or intervention performed in an emergency, to prolong the process of dying and where, in the judgment of the attending physician, death will occur whether or not the treatment is utilized. The term does not include the provision of appropriaty course of business or practice of a profession. 4. "Life-prolonging treatment" means any medical procedure, treatment, or intervention that, when administered to a qualified patient, will serve onlyts of subsection 1 of section 23-06.4-03. 3. "Health care provider" means a person who is licensed, certified, or otherwise authorized by the law of this state to administer health care in the ordinarires: 1. "Attending physician" means the physician who has primary responsibility for the treatment and care of the patient. 2. "Declaration" means a writing executed in accordance with the requiremenicide or permit any affirmative or deliberate act or omission to end life other than to permit the natural process of dying. 23-06.4-02. Definitions. In this chapter, unless the context otherwise requaged between each person and the person's family, the physician, and other health care providers. This chapter does not condone, authorize, approve, or permit mercy killing, euthanasia, or assisted sumedical care, including the decision to have medical or surgical means or procedures calculated to prolong the adult's life provided, withheld, or withdrawn. Communication about such matters is encour CHAPTER 23-06.4 (UNIFORM RIGHTS OF TERMINALLY ILL ACT) 23-06.4-01. Legislative intent. Every competent adult has the right and the responsibility to control the decisions relating to the adult's own based on Title 23 Chapter 23-06.4 Section 23-06.4-01 et. Seq. of the North Dakota Code. For your convenience, we have included useful excerpts from the North Dakota Statutes relating to Living Wills.Information and Instructions North Dakota Living Will This package contains (1) Information and Instruction for North Dakota Living Will; (2) North Dakota Living Will. This North Dakota Living Will is North Dakota