Living Will of Josephine Mae Diggle
I, Josephine Mae Diggle, revoke all prior living wills and all prior declarations to physicians and other interested persons if any, and declare this to be my last living will and declaration to take effect immediately.
I wish to live and enjoy life as long as possible. However I do not wish to receive experimental medical treatments, or health care that will only postpone the moment of my death from an incurable and terminal condition or that will only prolong my life if I have a permanent loss of consciousness. For purposes of this document, terminal condition means a condition that is reasonably expected to result in my death within twelve months regardless of the treatment that I may receive, and permanent loss of consciousness means a loss of consciousness from which there is no reasonable possibility that I will return to a cognitive and sapient life, and includes, but is not limited to, a persistent vegetative state.
Therefore, if two licensed and qualified physicians (neither of whom is related to me by blood, marriage, or adoption) have personally examined me, are familiar with my condition and have diagnosed and noted in my medical records either(1) that I have a terminal condition as defined above and that I am unable to receive and evaluate information effectively or to communicate decisions to such an extent that I lack the capacity to manage my health care decisions, or (2) that I have a permanent loss of consciousness, as defined above, then:
1. I direct that treatment or procedures that will only postpone the moment of death if I have a terminal condition, or that will only prolong my life if I have a permanent loss of consciousness, not be instituted or, if previously instituted , direct that they be discontinued.
2. I direct that procedures used to provide me with nutrition and hydration ( including, for example, but not limited to, misting and all forms of intravenous, parenteral, rectal, and tube feeding) be instituted and continue to be provided in the amount and kind determined by my physicians as to be necessary to prevent stressful dehydration, particularly of the mouth and skin, so as to maximize my life.
3. I direct that my physician or health care provider issue a “No Code” or “Do Not Resuscitate” order if I am diagnosed with a terminal illness or permanent loss of consciousness as described above.
4. I direct that my physician or health care provider order whatever is appropriate to keep me as comfortable and free of pain as possible, including the administration of pain-relieving drugs of any kind or other surgical or medical procedures calculated to relieve my pain, including unconventional pain-relief therapies that my physician or health care provider believes may be helpful, even though such drugs or procedures may have adverse side effects including permanent physical damage, may cause addiction, or may hasten the moment of (but not intentionally cause) my death.
I request that my directions and wishes as expressed in this instrument be carried out despite any contrary feelings, beliefs, or opinions of my family members, relatives, friends, conservator, or guardian.
For the purpose of inducing any person or entity (‘person”), including, but not limited to, any health care facility or health care provider to act in accordance with the directions given in this instrument, I represent, warrant, and agree that, except as provided below, I release and forever discharge any person who is or may be claimed to be liable to me, my estate, or my heirs, successors, or assigns, from all claims, demands, damages, actions, or suits of any kind, on account of all injuries or damages both to person and property that arises from that person’s acting in accordance with my directions as given in this instrument. I do not release or discharge any person from liability for negligence in the performance of acts performed in accordance with my directions as given in this instrument.
If any portion of this instrument is invalid or unenforceable under application of law, I direct that the balance of this instrument shall not be affected and shall continue in full force and effect.
I voluntarily have executed the instrument the ___________ day of ______, 20___.
_____________________________
Statement of witnesses
I know the person signing this document (“the declarant”), and I believe the declarant to be of sound mind. I believe the declarant’s execution of this document is voluntary. I am at least eighteen years of age, and I am not related to the declarant by blood, marriage, or adoption. To the best of my knowledge, I am not entitled to and do not have a claim on any portion of the declarant’s estate. I am not directly financially responsible for the declarant’s health care. I am not a health care provider who is involved in the declarant’s health care at this time. I am not an employ, other than a chaplain or social worker, of an inpatient health care facility in which the declarant is a patient.
______________ of _______________
______________ of _______________
I, Josephine Mae Diggle, revoke all prior living wills and all prior declarations to physicians and other interested persons if any, and declare this to be my last living will and declaration to take effect immediately.
I wish to live and enjoy life as long as possible. However I do not wish to receive experimental medical treatments, or health care that will only postpone the moment of my death from an incurable and terminal condition or that will only prolong my life if I have a permanent loss of consciousness. For purposes of this document, terminal condition means a condition that is reasonably expected to result in my death within twelve months regardless of the treatment that I may receive, and permanent loss of consciousness means a loss of consciousness from which there is no reasonable possibility that I will return to a cognitive and sapient life, and includes, but is not limited to, a persistent vegetative state.
Therefore, if two licensed and qualified physicians (neither of whom is related to me by blood, marriage, or adoption) have personally examined me, are familiar with my condition and have diagnosed and noted in my medical records either(1) that I have a terminal condition as defined above and that I am unable to receive and evaluate information effectively or to communicate decisions to such an extent that I lack the capacity to manage my health care decisions, or (2) that I have a permanent loss of consciousness, as defined above, then:
1. I direct that treatment or procedures that will only postpone the moment of death if I have a terminal condition, or that will only prolong my life if I have a permanent loss of consciousness, not be instituted or, if previously instituted , direct that they be discontinued.
2. I direct that procedures used to provide me with nutrition and hydration ( including, for example, but not limited to, misting and all forms of intravenous, parenteral, rectal, and tube feeding) be instituted and continue to be provided in the amount and kind determined by my physicians as to be necessary to prevent stressful dehydration, particularly of the mouth and skin, so as to maximize my life.
3. I direct that my physician or health care provider issue a “No Code” or “Do Not Resuscitate” order if I am diagnosed with a terminal illness or permanent loss of consciousness as described above.
4. I direct that my physician or health care provider order whatever is appropriate to keep me as comfortable and free of pain as possible, including the administration of pain-relieving drugs of any kind or other surgical or medical procedures calculated to relieve my pain, including unconventional pain-relief therapies that my physician or health care provider believes may be helpful, even though such drugs or procedures may have adverse side effects including permanent physical damage, may cause addiction, or may hasten the moment of (but not intentionally cause) my death.
I request that my directions and wishes as expressed in this instrument be carried out despite any contrary feelings, beliefs, or opinions of my family members, relatives, friends, conservator, or guardian.
For the purpose of inducing any person or entity (‘person”), including, but not limited to, any health care facility or health care provider to act in accordance with the directions given in this instrument, I represent, warrant, and agree that, except as provided below, I release and forever discharge any person who is or may be claimed to be liable to me, my estate, or my heirs, successors, or assigns, from all claims, demands, damages, actions, or suits of any kind, on account of all injuries or damages both to person and property that arises from that person’s acting in accordance with my directions as given in this instrument. I do not release or discharge any person from liability for negligence in the performance of acts performed in accordance with my directions as given in this instrument.
If any portion of this instrument is invalid or unenforceable under application of law, I direct that the balance of this instrument shall not be affected and shall continue in full force and effect.
I voluntarily have executed the instrument the ___________ day of ______, 20___.
_____________________________
Statement of witnesses
I know the person signing this document (“the declarant”), and I believe the declarant to be of sound mind. I believe the declarant’s execution of this document is voluntary. I am at least eighteen years of age, and I am not related to the declarant by blood, marriage, or adoption. To the best of my knowledge, I am not entitled to and do not have a claim on any portion of the declarant’s estate. I am not directly financially responsible for the declarant’s health care. I am not a health care provider who is involved in the declarant’s health care at this time. I am not an employ, other than a chaplain or social worker, of an inpatient health care facility in which the declarant is a patient.
______________ of _______________
______________ of _______________