Fill and Sign the Declaration Montana State University Form

DECLARATION If I should have an incurable and irreversible condition that, without the administration of life- sustaining treatment, will, in the opinion of my attending physician, cause my death within a relatively short time, and I am no longer able to make decisions regarding my medical treatment, I appoint ________________________________ or, if he or she is not reasonably available or is unwilling to serve, ________________________________, to make decisions on my behalf regarding withholding or withdrawal of treatment that only prolongs the process of dying and is not necessary for my comfort or to alleviate pain, pursuant to NRS 449A.400 to 449A.481, inclusive. (If the person or persons I have so appointed are not reasonably available or are unwilling to serve, I direct my attending physician, pursuant to those sections, to withhold or withdraw treatment that only prolongs the process of dying and is not necessary for my comfort or to alleviate pain.) Strike language in parentheses if you do not desire it. If you wish to include this statement in this declaration, you must INITIAL the statement in the box provided: Withholding or withdrawal of artificial nutrition and hydration may result in death by starvation or dehydration. Initial this box if you want to receive or continue receiving artificial nutrition and hydration by way of the gastro-intestinal tract after all other treatment is withheld pursuant to this declaration. [ ] Signed THIS ______ day of ________________________________ , 20______Signature: __________________________________________ Address: ________________________________________________________________ The declarant voluntarily signed this writing in my presence. Signature: __________________________________________ Address: __________________________________________ __________________________________________ Print Name: __________________________________________ Signature: __________________________________________ Address: __________________________________________ __________________________________________ Print Name: __________________________________________ Name and address of each designee. Name: ________________________________ Address: ________________________________________________________________ Name: ________________________________ Address: ________________________________________________________________