Statutory Declaration in Conformance with Florida Life Prolonging Procedure Act, F.S. 765.05
DECLARATION OF ________________________
Declaration made this __________ day of _____________ 20________. I ___________ willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, do hereby declare:
If at any time I should have a terminal condition, and if my attending physician has determined that there can be no recovery from such condition and my death is imminent, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me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.
In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this declaration shall be honored by my family and physicians as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences for such refusal.
If I have been diagnosed as pregnant and that diagnosis is known to my physician, this declaration shall have no force or effect during the course of my pregnancy.
I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration.
_______________________________________
_______________________________________
City of residence: _____________________
County of residence: ___________________
State of residence: ____________________
Date: ________________________
The Declarant has been personally known to me and I believe him or her to be of sound mind.
Witness: ___________________________________________
Witness: ___________________________________________
Date: ___________________________
Statutory Declaration in Conformance with Florida Life Prolonging Procedure Act, F.S. 765.05
Review List
This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in Florida. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.
1. Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.
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