HEALTH CARE DIRECTIVE
TO: My family, physicians and all those concerned with my care:
I, **, presently residing at *, and being an adult of sound mind, make this
declaration as a directive to be followed if for any reason I become unable to make or
communicate decisions regarding my medical care.
If I am determined by two doctors, one of whom is my family physician, to be in
a persistent vegetative state and there is no reasonable expectation of recovery therefrom, or to
be suffering from a terminal illness or condition, and am determined to be in the end stages of
that illness or condition, I direct that all life-prolonging procedures be withheld or withdrawn,
unless they are necessary to keep me comfortable and to relieve pain. The procedures and
treatment to be withheld and withdrawn include, without limitation, surgery, antibiotics, cardiac
and pulmonary resuscitation, and dialysis, chemotherapy, radiation therapy, mechanical
ventilator and respiratory support. I expressly authorize the withholding and withdrawal of
artificially provided food, water, and other nourishment and fluids.
I wish to live out my last days at home rather than in a hospital, if it does not
impose an undue burden on my family.
These directions are the exercise of my legal right to refuse treatment. Therefore,
I expect my family, physicians, health care facilities and all concerned with my care to regard
themselves as legally and morally bound to act in accordance with my wishes, and in so doing to
be free from any liability for having followed my directions.
I am preparing this Health Care Directive simultaneously with a Power of
Attorney for Medical Care. I hereby direct and authorize my Healthcare Agent designated
therein, to make the determination of whether or not to follow the directions herein, depending
upon the facts and circumstances presented at the time, and following consultation with all
appropriate physicians. The decision of my Healthcare Agent shall be exclusive and
determinative.
IN WITNESS WHEREOF, I have executed this declaration, as my free and
voluntary act and deed, this * day of ****, 2010.
___________________________________
**
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WITNESS:
We, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ and
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _, each hereby attest and declare under
penalty of perjury under the laws of the State of Missouri that: (1) the foregoing instrument was
personally signed by ** in my presence, and thereupon I, at his request and in his presence and in
the presence of the other witnesses, have hereunto subscribed my name as a witness; (2) I did not
sign the above signature of ** for or at his direction; (3) I personally know ** and believe him to
be of sound mind and under no constraint, duress, fraud or undue influence; (4) I am not related
to ** by blood, marriage or adoption; (5) I am not entitled (to the best of my knowledge and
belief) to any portion of the estate of ** upon his death under any will or codicil of ** or by
operation of law; (6) I do not have any present or inchoate claim against any portion of the estate
of **; (7) I do not have any financial responsibility for the medical care of **; (8) I am not a
physician or an employee of any physician, and I am not an operator or employee of, or patient
in, any hospital, health care provider, residential care facility, community care facility, skilled
nursing facility or similar institution; and (9) I and ** are both at least 18 years of age.
Dated: **, 2010
______________________________________
residing at
_________________________________
_________________________________
______________________________________
residing at
_________________________________
_________________________________
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STATE OF MISSOURI
COUNTY OF ST. LOUIS
)
) ss.
)
I, the undersigned, an officer authorized to administer oaths, certify that **, and
____________________________________,
__________________________________,
the
witnesses, whose names are subscribed to the attached or foregoing instrument, having appeared
together before me and first having been duly sworn, each then declared to me that ** signed and
executed the instrument as his Health Care Directive, and that he had willingly made and executed
it as his free and voluntary act and deed for the purposes therein expressed; and that each of the
witnesses, in the presence and hearing of ** and each other, and at the request of **, signed the
Health Care Directive as witnesses; and to the best of their knowledge ** was at the time at least
eighteen years of age, and was of sound mind and under no constraint, duress, fraud or undue
influence; and that each of said witnesses was then at least eighteen years of age.
IN WITNESS WHEREOF, I have hereunto subscribed my name and official seal.
_______________________________
David A. Rubin
Notary Public
Commissioned in St. Louis County, Missouri
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