...Advance Directives, Continued

Important Notice: National Public Radio is providing sample documents from the State of Florida so that you can familiarize yourself with the types of provisions and decision making an individual faces when executing a legal document of this sort. Requirements for these directives, indeed the laws governing the interpretation of these sorts of documents, vary from State to State. You should obtain advance directives specifically designed for use in your State.

FLORIDA LIVING WILL

Declaration made this ____ day of ___________, 19 ____.

I, ______________S A M P L E______________________, willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do hereby declare:

If at any time I have a terminal condition and if my attending or treating physician and another consulting physician have determined that there is no medical probability of my recovery from such condition, I direct that life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only the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.

It is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences for such refusal.

In the event that I have been determined to be unable to provide express and informed consent regarding the withholding, withdrawal, or continuation of life-prolonging procedures, I wish to designate, as my surrogate to carry out the provisions of this declaration:

Name: ____________________________________________________

Address: __________________________________________________

________________________________ Zip Code: _________

Phone: ___________________________________________________

I wish to designate the following person as my alternate surrogate, to carry out the provisions of this declaration should my surrogate be unwilling or unable to act on my behalf:

Name: ____________________________________________________

Address: __________________________________________________

_____________________________ Zip Code: _________

Phone: ___________________________________________________

Additional instructions (optional):

I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration.

Signed: ___________________________________________________

Witness 1:

Signed: ________________________________________________

Address: _______________________________________________

Witness 2:

Signed: ________________________________________________

Address: _______________________________________________



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