[This is a SAMPLE Text]

DECLARATION ON LIFE AND DEATH

This Declaration on Life and Death, made while I am of sound mind, is provided as a means of indicating my desires and directions regarding treatment of care for me in the event I become irreversibly and terminally ill.

I therefore admonish and direct my family, physicians, lawyer, pastor, and friends that, because of my belief in the dignity of the human person and my eternal destiny in God, if I become irreversibly, incurably, and terminally ill, I be fully informed of the facts so that I can prepare myself spiritually to die.

I have the right to make my own decisions concerning treatment that might inordinately prolong the dying process beyond the limits dictated by reason and good judgment. If I should have an incurable injury, disease or illness, certified to be a terminal condition by two physicians who have examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not the life-sustaining procedures are utilized and where the application of life-sustaining procedures would serve only to artificially prolong the dying process; and if I am unable to make my own decisions and have no reasonable expectation of recovery, then I request and direct that no ethically extraordinary means be used to prolong my life, but that my pain be alleviated. (The term "ethically extraordinary means" signifies treatment that does not offer a reasonable hope of benefit to me, and that cannot be accomplished without excessive expense, pain, or other grave burden.) Nothing should be done with the intention of shortening or terminating my life.

As a general rule, nutrition and hydration are ordinary means, whether being administered orally or artificially, and they are not to be withheld or withdrawn from me, except that where there is clear and convincing evidence, in the judgment of my physicians, that they are causing me harm, are useless, or are excessively burdensome; only then they can be withheld or withdrawn.

If I am pregnant and that condition is known to my physician, then every means shall be taken to preserve and nurture the life of my unborn child, including the continuation of life-prolonging procedures.

I hereby designate _____________________ or, if he/she is unwilling or unable to act, then ____________________________ as alternate, to make medical treatment decisions for me, including decisions to withhold or withdraw life-prolonging procedures, should I be diagnosed as suffering from a terminal condition and comatose, incompetent or otherwise mentally or physically incapable of communication.

I request that my family, my church community, and all my friends join me in prayer and sacrifice as I prepare for death.

Signed this ________ day of ________, 20____

(Signature) ___________________________________________

The declarant is personally known to me and I believe him/her to be of sound mind.

(Witness)____________________________________

(Address)_________________________________________

 

(Witness)___________________________________

(Address)_________________________________________

 

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[adapted from Catholic International, vol.5, no.6]