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: ___________________
