by Shale Fri Jan 20, 2012 10:40 am
My wishes are known by family and doctors and has been written down and copies given to them:
Declaration made this 12th day of September 2010.
I, Shale Stone, willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and do hereby declare that, if at any time I am incapacitated, have a terminal condition, an end-stage condition or am in a persistent vegetative state and if my attending or treating physician and another consulting physician have determined that there is no medical probability of my recovery from such condition, I direct that life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain.
It 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 to accept the consequences for such refusal.
In the event that I have been determined to be unable to provide express and informed consent regarding the withholding, withdrawal, or continuation of life prolonging procedures, I wish to designate, as my surrogate to carry out the provisions of this declaration:
(Grandson - since my bank accounts are In Trust For my daughter)
I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration.
ADDITIONAL INSTRUCTIONS:
Measures of artificial life-support in the face of impending death that I specifically refuse are:
• Electrical or mechanical resuscitation of my heart (CPR) when it has stopped beating.
• Mechanical respiration when I am no longer able to sustain my own breathing.
• Gastric or naso-gastric tube feeding, or parenteral nourishment when I am paralyzed or unable to take nourishment by mouth.
SIGNED: __________________________________ DATE: 09-12-10
Shale Stone
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