Fill and Sign the Indiana Living Will Declaration Indiana Power of Attorney for Form

LIVING WILL DECLARATION (Indiana Code 16-36-4-10) Declaration made this ___ day of ___________, 20___(month, year). I, ________________________, being at least eighteen (18) years of age and of sound mind, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below, and I declare: If at any time my attending physician certifies in writing that: (1) I have an incurable injury, disease, or illness; (2) my death will occur within a short time; and (3) the use of life prolonging procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the performance or provision of any medical procedure or medication necessary to provide me with comfort care or to alleviate pain, and, if I have so indicated below, the provision of artificially supplied nutrition and hydration. (Indicate your choice by initialing or making your mark before signing this declaration): _______ I wish to receive artificially supplied nutrition and hydration, even if the effort to sustain life is futile or excessively burdensome to me. _______ I do not wish to receive artificially supplied nutrition and hydration, if the effort to sustain life is futile or excessively burdensome to me. _______ I intentionally make no decision concerning artificially supplied nutrition and hydration, leaving the decision to my health care representative appointed under IC 16-36-1-7 or my attorney in fact with health care powers under IC 30-5-5. In the absence of my ability to give di
E, I declare that i have done so freely, knowingly, and willingly without undue influence or oppression except that, in the event of the receipt of artificial nutrition and hydration under these circumstances, my attending physician or health care representative acting in good faith should be entitled to reasonable compensation under section for medical and laboratory costs directly related to such provision; for the reasonable cost of treatment of illnesses or disorders resulting from my inability to obtain care or treatment necessitated by my inability to remain still, if I am able to be so sustained; for the reasonable cost for the provision of other assistance to alleviate suffering; for costs of nursing attendants, attendants' aids, hospice technicians and hospice nurses; for medical equipment, drugs, and supplies for the care of myself or my personal effects; for necessary hospitalization for illness or injury; and for reasonable medical charges in connection with the administration of this declaration. I acknowledge that this declaration may be challenged in a court of competent jurisdiction, provided that my declaration of intention to die is supported by written certification from a medically qualified physician that I am incompetent to waive these medical and laboratory benefits or other assistance to relieve suffering which I have requested and that i have been informed through consultation with and advice from a medically qualified physician that it may be useful in obtaining a diagnosis and treatment for this illness to obtain artificial nutrition and hydration in my dying process. Any such challenge should be submitted to me within thirty (30) days. (signature and marking) declaration of intention to refuse medical treatment in the form of artificial nutrition and hydration (Indiana code 18-1-1-13(b)) declaration made this day of , 20(month, year). I, , being at least eighteen (18) years of age and of sound mind, am a resident of Indiana, united states, and wish to refuse, for myself, and for my spouse and any other surviving minor dependents: artificial nutrition and hydration. (indiana code 18-1-1-13(b)), even if the effort to sustain life would be futile or excessively burdensome to me. I make this declaration pursuant to section 2d of the Indiana code, to be effective as of the date set forth above. I further declare that the foregoing statements are true and correct to the best of my knowledge and belief. Furthermore, I do solemnly swear or affirm that i will not provide artificial nutrition and hydration to any person at any time.