Taking Care of Mom and Dad: Sample Health Care Declaration
I, [YOUR PARENT'S FULL NAME], being of sound mind, desire that, as specified below, my life not be prolonged by extraordinary means or by artificial nutrition or hydration if my condition is determined to be terminal and incurable or if I am diagnosed as being in a persistent vegetative state. I am aware and understand that this writing authorizes a physician to withhold or discontinue extraordinary means or artificial nutrition or hydration, in accordance with my specifications set forth below:
(Initial any of the following, as desired):
____ If my condition is determined to be terminal and incurable, I authorize the following:
____ My physician may withhold or discontinue extraordinary means only.
____ In addition to withholding or discontinuing extraordinary means if such means are necessary, my physician may withhold or discontinue either artificial nutrition or hydration, or both.
____ If my physician determines that I am in a persistent vegetative state, I authorize the following:
____ My physician may withhold or discontinue extraordinary means only.
____ In addition to withholding or discontinuing extraordinary means if such means are necessary, my physician may withhold or discontinue either artificial nutrition or hydration, or both.
[DATE]
[YOUR PARENT'S SIGNATURE]
I hereby state that the declarant, [YOU PARENT'S NAME], being of sound mind signed the above declaration in my presence and that I am not related to the declarant by blood or marriage and that I do not know or have a reasonable expectation that I would be entitled to any portion of the estate of the declarant under any existing will or codicil of the declarant or as an heir under the Intestate Succession Act if the declarant died on this date without a will. I also state that I am not the declarant's attending physician or an employee of the declarant's attending physician, or an employee of a health facility in which the declarant is a patient or an employee of a nursing home or any group-care home where the declarant resides. I further state that I do not now have any claim against the declarant.
[WITNESS' SIGNATURE]
[WITNESS' SIGNATURE]
[NOTARY OR COURT CLERK'S STATEMENT AND STAMP]
