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Rhode Island ess: ______________________________________ _________________________________ Address: ______________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Addr__________________________ The declarant is personally known to me and voluntarily signed this document in my presence. _____________________________________________ (Witness Signature) Print Name: ________ __________________________________________ (Declarant's Signature) Address: __________________________________________________________________ ______________________________________ Zip Code: _authorization includes [__] does not include [__] the withholding or withdrawal of artificial feeding (check only one box above). Signed this __________________ day of __________________, ____________egarding my medical treatment, I direct my attending physician to withhold or withdraw procedures that merely prolong the dying process and are not necessary to my comfort, or to alleviate pain. This tificially prolonged under the circumstances set forth below, do hereby declare: If I should have an incurable or irreversible condition that will cause my death and if I am unable to make decisions rgalforms.com Living Will DECLARATION I, ______________________________________________________________ being of sound mind willfully and voluntarily make known my desire that my dying shall not be arssible 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 findleused 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 with estate planning matters. Any poforms 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 e 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 legal effect or completeness. [_]These gency medical services personnel upon communication to that physician health care provider or emergency medical services personnel by the declarant or by another who witnessed the revocation. [_] Thesliable documentation as defined in § 23-4.11-2(6) shall constitute a revocation of the declaration. (b) A revocation is only effective as to the attending physician or any health care provider or emerhis title, both of which have been executed by the same person, the latter executed document shall control as to any inconsistent provision. (4) For emergency medical services personnel, absence of re declarant's medical record. (3) If there is an inconsistency between a declaration executed pursuant to this chapter and a durable health care power of attorney executed pursuant to chapter 4.10 of tation to that physician or health care provider by the declarant or by another who witnessed the revocation. (2) The attending physician or health care provider shall make the revocation a part of thearant is able to communicate an intent to revoke, without regard to mental or physical condition. A revocation is only effective as to the attending physician or any health care provider upon communic. (d) A declaration may, but need not, be in the following form: (see form below) § 23-4.11-4 Revocation of declaration (a) A declaration may be revoked at any time and in any manner by which the declg physician; Information & Instructions ­ Page 3 (2) The declarant is determined by the attending physician to be in a terminal condition; and (3) The declarant is unable to make treatment decisions who is provided a copy of the declaration shall make it a part of the declarant's medical record. (c) A declaration has operative effect only when: (1) The declaration is communicated to the attendinarant, or another at the declarant's direction in the presence of two (2) subscribing witnesses who are not related to the declarant by blood or marriage. (b) A physician or other health care providert individual eighteen (18) years of age or older may at any time execute a declaration governing the withholding or withdrawal of life sustaining procedures. The declaration must be signed by the declhe administration of life sustaining procedures, will, in the opinion of the attending physician, result in death. § 23-4.11-3 Declaration relating to use of life sustaining procedures. (a) A competenies and certifies that a valid and current declaration is on file and that the individual is a qualified patient. (13) "Terminal condition" means an incurable or irreversible condition that, without tbracelet of uniform design, adopted by the director of health, with consultation from the local community emergency medical services agencies and licensed hospice and home health agencies, that signifs been determined by the attending physician to be in a terminal condition. (12) "Reliable documentation" means a standardized, state-wide form of identification such as a nontransferable necklace or ty. (10) "Physician" means an individual licensed to practice medicine in this state. (11) "Qualified patient" means a patient who has executed a declaration in accordance with this chapter and who ha care or alleviate pain. (9) "Person" means an individual, corporation, business trust, estate, trust, partnership, association, government, governmental subdivision or agency, or any other legal entiwill serve only to prolong the dying process. "Life sustaining procedure" shall not include any medical procedure or intervention considered necessary by the attending physician to provide comfort andhealth care in the ordinary course of business or practice of a profession. (8) "Life sustaining procedure" means any medical procedure or intervention that, when administered to a qualified patient, personnel acting within the ordinary course of their professions. (7) "Health care provider" means a person who is licensed, certified, or otherwise authorized by the law of this state to administer ctions ­ Page 2 (6) "Emergency medical services personnel" means paid or volunteer firefighters, law enforcement officers, first responders, emergency medical technicians, or other emergency servicesnt and care of the patient. (4) "Declaration" means a witnessed document executed in accordance with the requirements of § 23-4.11-3. (5) "Director" means the director of health. Information & Instruydration by parenteral, nasogastric, gastric or any means other than through per oral voluntary sustenance. (3) "Attending physician" means the physician who has primary responsibility for the treatmee ambulance service advisory board, of providing palliative care to, and withholding lifesustaining procedures from, a qualified patient. (2) "Artificial feeding" means the provision of nutrition or hconstruction of this chapter: (1) "Advance directive protocol" means a standardized, state-wide method developed for emergency medical services personnel by the department of health and approved by thten declaration instructing his or her physician to withhold or withdraw life sustaining procedures in the event of a terminal condition. § 23-4.11-2 Definitions. The following definitions govern the ven after they are no longer able to participate actively in decisions about themselves, the legislature declares that the laws of the state shall recognize the right of an adult person to make a writheir own medical care, including the decision to have life sustaining procedures withheld or withdrawn in instances of a terminal condition. (b) In order that the rights of patients may be respected es. CHAPTER 23-4.11 Rights of the Terminally Ill Act § 23-4.11-1 Purpose. (a) The legislature finds that adult persons have the fundamental right to control the decisions relating to the rendering of t based on Title 23 Chapter 23-4.11 section 23-4.11-1 et. Seq. of the Rhode Island Statutes For your convenience, we have included useful excerpts from the Rhode Island Statutes relating to Living WillInformation and Instructions Rhode Island Living Will This package contains (1) Information and Instruction for Rhode Island Living Will; (2) Rhode Island Living Will. This Rhode Island Living Will is Rhode Island