Can I sign electronically?

Yes, in most states electronic signatures are valid under the ESIGN Act and UETA when execution requirements are met; some states may still require notarization or witnesses, so confirm local rules.

Are witnesses required?

Witness requirements vary by state; some states require two witnesses, others none. Follow your state statute or form instructions to ensure clinical acceptance.

Do hospitals accept digital copies?

Many hospitals accept scanned or electronically signed directives when provenance and signatures are verifiable; integrate the final record into the EHR for availability at point of care.

How do I revoke a declaration?

You may typically revoke by executing a written revocation, creating a new directive, or communicating the revocation to treating clinicians; keep dated proof of revocation.

Is a notary required?

Some states or facilities require a notary or a self-proving affidavit; where required, use in-person or authorized RON processes that meet state standards.

What if family disagrees?

If surviving family disputes the directive, courts may be asked to adjudicate; clear, current directives reduce the likelihood of expensive and time-consuming litigation.

Electronic Signature
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Declaration Regarding Life-Sustaining Procedures

Declaration Regarding Life-Sustaining Procedures

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

DECLARATION

(K.S.A. 65-28,103)

Declaration made this day of (month, year). I, being of sound mind, 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 an incurable injury, disease, or illness certified to be a terminal condition by two physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life-sustaining procedures are utilized and where the application of life-sustaining procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care.

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 physician(s) as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.

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

Signed:

City, County and State of Residence:

The declarant has been personally known to me and I believe the declarant to be of sound mind. I did not sign the declarant's signature above for or at the direction of the declarant. I am not related to the declarant by blood or marriage, entitled to any portion of the estate of the declarant according to the laws of intestate succession or under any will of declarant or codicil thereto, or directly financially responsible for declarant's medical care.

Witness

(OR)

STATE OF

COUNTY OF

This instrument was acknowledged before me on by (name of person).

(Seal, if any)

My appointment expires:

What the Declaration Regarding Life-Sustaining Procedures Is

A Declaration Regarding Life-Sustaining Procedures (often called a living will or advance directive) is a written statement that records a person's preferences about medical treatments if they cannot communicate due to incapacity. It specifies whether to withhold or withdraw life-sustaining interventions such as mechanical ventilation, cardiopulmonary resuscitation, artificial nutrition or hydration, and other life-prolonging measures. The document may name a healthcare agent or surrogate and can include conditions under which instructions apply, helping clinicians and family members follow the patient’s wishes.

Why a Clear Declaration Matters

A signed declaration ensures medical teams and loved ones have authoritative guidance about your treatment preferences during incapacity. It reduces family conflict, supports patient autonomy, and documents choices that affect end-of-life care and medical decision making.

Who Typically Completes This Declaration

Health systems, legal advisers, and caregivers also reference the declaration during care transitions to confirm treatment limits and surrogate authority.

Patients and competent adults who wish to record treatment preferences in advance.
Designated healthcare agents or proxies preparing to confirm their authority.
Clinicians and hospital administrators who need a clearly executed directive on file.

Core Elements Every Professional Declaration Should Include

A complete Declaration Regarding Life-Sustaining Procedures combines clear instructions, signatory data, and authentication to ensure it is actionable by medical teams.

Treatment Choices

Specific statements about CPR, ventilation, artificial nutrition/hydration, antibiotics, dialysis and other life-sustaining measures so clinicians know which interventions to provide or withhold.

Trigger Conditions

Definitions of the clinical circumstances when instructions apply (e.g., irreversible coma, terminal condition, permanent vegetative state) to reduce interpretation disputes.

Healthcare Agent

Name and contact of a chosen surrogate decision-maker with authority to accept or refuse treatment consistent with the declaration and state law.

Signature Block

Signatures, dates, and witness or notary acknowledgements required by state law to validate the document for clinical use.

Revocation Terms

Clear instructions on how to revoke or amend the document, including whether a later oral or written statement supersedes it.

Additional Wishes

Optional sections for organ donation, palliative care preferences, and specific religious or cultural instructions about end-of-life care.

Step-by-Step: Completing the Declaration

Follow this sequence to produce a legally effective declaration that clinicians can rely on.

01

Gather Information: Collect legal name, DOB, contact details, and agent information.
02

Decide Preferences: Specify yes/no choices and any conditional statements.
03

Execute Properly: Sign in front of required witnesses or notary as your state law requires.
04

Distribute Copies: Provide copies to your healthcare agent, primary clinician, and hospital record.

Configuring an Online Workflow for the Declaration

Set up an eSignature workflow so completion, authentication, and distribution are auditable and secure.

Field	Configuration
Signature Field	Require signer to adopt signature and capture date stamp.
Witness Fields	Add witness name, signature, and date fields when state law requires.
Notary Block	Reserve space for notary acknowledgement or RON session details if used.
Delivery	Auto-send final signed copy to signer, agent, and healthcare record.

Technical and Security Considerations for eSigning

Ensure the chosen platform offers a Business Associate Agreement (BAA) for HIPAA-covered entities and preserves a tamper-evident audit trail for legal and clinical use.

Data Encryption: TLS 1.2/1.3 in transit and AES-256 at rest.
Authentication: Support email, SMS, and advanced signer verification options.
Integrations: Compatibility with EHR, cloud storage, and SSO systems.

How to Send, Sign, and Store the Declaration

A clear sending and storage flow reduces delays and ensures the declaration is available when needed.

Upload Document: Upload the completed form PDF or template to your eSignature platform.
Place Fields: Add signature, witness, and date fields in the correct sequence.
Authenticate Signers: Use chosen authentication (email, SMS code, or ID verification).
Distribute Copies: Deliver executed copies to agent, provider, and a secure records system.

Timing: When to Execute and When to Review

Documentation timing impacts enforceability and relevance; execute before planned procedures and review periodically.

Before Major Treatment:

Execute well before elective surgeries or treatments to ensure documents are on file.

After Diagnosis:

Complete or update the declaration promptly after a serious diagnosis or health status change.

Periodic Review:

Review every 2–3 years or after major life events to confirm choices remain current.

Upon Relocation:

Recheck state requirements after moving; update execution to conform with new jurisdiction.

At Care Transitions:

Provide a current copy when admitted to a hospital, long-term care, or hospice facility.

Common Errors That Undermine the Declaration

Using vague language like 'do everything' which leaves clinical teams uncertain about specific interventions.
Failing to sign, date, or have required witnesses/notary present, creating questions about validity at point of care.
Not distributing copies to the healthcare agent and treating facility, delaying application of the declaration when needed.
Relying on an out-of-date form that conflicts with a more recent written or recorded revocation.

Legal and Practical Risks of an Incorrect Declaration

Invalidation Risk: Document may be disregarded if execution requirements are unmet.

Clinical Disputes: Unclear instructions can prompt family disagreement and legal intervention.

HIPAA Violations: Improper disclosures risk penalties under 45 CFR §164.502.

I-9/Tax Irrelevance: Not applicable to employment forms; ensure you do not conflate different legal documents.

Criminal Liability: Assisting fraudulently executed documents can carry criminal exposure.

Probate Delays: Disputed directives may lead to probate or guardianship proceedings.

Comparing eSignature Providers for This Declaration

Pricing and feature sets vary; below is a concise comparison of signNow and common alternatives for executing and managing advance directives.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Trial available	Trial available	Trial available	Trial available
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies by plan	Varies by plan	Varies by plan

Frequently Asked Questions About Declarations Regarding Life-Sustaining Procedures

Answers to common legal and practical questions about completing, signing, and using the declaration in clinical settings.

Need help? Contact support

Can I sign electronically?
Yes, in most states electronic signatures are valid under the ESIGN Act and UETA when execution requirements are met; some states may still require notarization or witnesses, so confirm local rules.
Are witnesses required?
Witness requirements vary by state; some states require two witnesses, others none. Follow your state statute or form instructions to ensure clinical acceptance.
Do hospitals accept digital copies?
Many hospitals accept scanned or electronically signed directives when provenance and signatures are verifiable; integrate the final record into the EHR for availability at point of care.
How do I revoke a declaration?
You may typically revoke by executing a written revocation, creating a new directive, or communicating the revocation to treating clinicians; keep dated proof of revocation.
Is a notary required?
Some states or facilities require a notary or a self-proving affidavit; where required, use in-person or authorized RON processes that meet state standards.
What if family disagrees?
If surviving family disputes the directive, courts may be asked to adjudicate; clear, current directives reduce the likelihood of expensive and time-consuming litigation.

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