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Back to Forms for 'Living Wills'.


DECLARATION OF A DESIRE FOR A NATURAL DEATH

DECLARATION OF A DESIRE FOR A NATURAL DEATH

(North Carolina Only)

 

 

TO MY FAMILY, MY PHYSICIAN, MY LAWYER, MY CLERGYMAN, TO ANY MEDICAL FACILITY IN WHOSE CARE I HAPPEN TO BE, TO ANY INDIVIDUAL WHO MAY BECOME RESPONSIBLE FOR MY HEALTH, WELFARE OR AFFAIRS

 

 

Death is as much a reality as birth, growth, maturity and old age; it is the one certainty of life.  If the time comes when I, __________________________, can no longer take part in decisions for my own future, let this statement stand as an expression of my wishes, while I am still of sound mind.

 

If the situation should arise in which there is no reasonable expectation of my recovery from physical or mental disability, I desire that I be allowed to die and that my life not be prolonged by extraordinary means.  However, I do not fear death itself as much as the indignities of deterioration, dependence and hopeless pain.  I, therefore, ask that medication be mercifully administered to me to alleviate suffering, even though this may hasten the moment of death.

 

This request is made after careful consideration; I hope you who care for me will feel morally bound to follow its mandate.  I recognize that this appears to place a heavy responsibility upon you, but it is with the intention of relieving you of such responsibility and of placing it upon myself in accordance with my strong convictions, that this statement is made.

 

THEREFORE, I, _________________________, 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 permanently in a coma, suffer severe dementia, 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: 

 

______  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 permanently in a coma, suffer severe dementia, or 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.

 

This the _________ day of _______________ (month), ______ (year).

 

 

___________________________________ (Seal)

 

 

I hereby state that the declarant, __________________________________, 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 care facility in which the declarant is a patient or an employee of a nursing home or any group home where the declarant resides.  I further state that I do not now have any claim against the declarant.

 

 

_________________________                   _______________

Witness                                                         Date

 

 

_________________________                   _______________

Witness                                                         Date

 

 

I, _____________________________, a Notary Public for _________________ County, hereby certify that _____________________________________, the declarant, appeared before me and swore to me and to the witnesses in my presence that this instrument is ________________ (His/Her) Declaration of a Desire for a Natural Death, and that ____ (He/She) had willingly and voluntarily made and executed it as a free act and deed for the purposes expressed in it.

 

I further certify that ___________________________________________________ and _____________________________________, witnesses, appeared before me and swore that they witnessed ________________________________________, declarant, sign the attached declaration, believing __________ (Him/Her) to be of sound mind; and also swore that at the time they witnessed the declaration (i) they were not related within the third degree to the declarant or to the declarant's spouse, and (ii) they did not know or have a reasonable expectation that they would be entitled to any portion of the estate of the declarant upon the declarant's death under any will of the declarant or codicil thereto then existing or under the Intestate Succession Act as it provides at that time, and (iii) they were not a physician attending the declarant or an employee of an attending physician or an employee of a health facility in which the declarant was a patient or an employee of a nursing home or any group home in which the declarant resides, and (iv) they did not have a claim against the declarant.  I further certify that I am satisfied as to the genuineness and due execution of the declaration.

 

This the __________ day of ________________ (month), _____(year).

 

 

 

___________________________________

Notary Public

 

My Commission Expires: ___________________

 



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