(The following is a near verbatim recitation of the
language contained in Tennessee Code Annotated sec. 32-11-105. This language
is recognized as an "Advance Directive" by health care providers
in the State of Tennessee and no representation is made to the contrary.
If you reside in a state other than Tennessee it is advised that you obtain
a form for use in the state of your residence)
I, ___________________________, willfully and voluntarily make known
my desire that my dying shall not be artificially prolonged under the
circumstances set forth below, and do hereby declare:
If at any time I should have a terminal condition and my attending physician
has determined that there is no reasonable medical expectation of recovery
and which, as a medical probability, will result in my death, regardless
of the use or discontinuance of medical treatment implemented for the
purpose of sustaining life, or the life process, I direct that medical
care be withheld or withdrawn, and that I be permitted to die naturally
with only the administration of medications or the performance of any
medical procedure deemed necessary to provide me with comfortablecare
or to alleviate pain.
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ARTIFICIALLY
PROVIDED NOURISHMENT AND FLUIDS:
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By checking the
appropriate line below, I specifically:
________ Authorize
the withholding or withdrawal of artificially provided food, water or
other nourishment or fluids.
________ DO NOT
authorize the withholding or withdrawal of artificially provided food,
water or other nourishment or fluids.
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ORGAN
DONOR CERTIFICATION:
|
Not withstanding
my previous declaration relative to the withholding or withdrawal of
life-prolonging procedures, if as indicated below I have expressed my
desire to donate my organs and/or tissues for transplantation, or any
of them as specifically designated herein, I do direct my attending
physician, if I have been determined dead according to Tennessee Code
Annotated section 68-3-501(b), to maintain me on artificial support
systems only for the period of time require to maintain the viability
of and to remove such organs and/or tissues.
By checking the
appropriate line below, I specifically:
________ Desire to donate my organs and/or tissues for transplantation.
________ Desire
to donate my ________________________________________
(Insert specific organs and/or tissues for transplantation)
________ DO NOT:
desire to donate my organs or tissues for transplantation.
In the absence
of my ability to give directions regarding my medical care, it is my
intention that this declaration shall be honored by my family and physician
as the final expression of my legal right to refuse medical care and
accept the consequences of such refusal.
The definitions of terms used herein shall be as set forth in the Tennessee
Right to Natural Death Act, Tennessee Code Annotated section 32-11-103.
I understand the full import of this declaration, and I am emotionally
and mentally competent to make this declaration.
In acknowledgment whereof, I do hereinafter affix my signature on this
the ________ day of __________, 20___.
__________________________________
DECLARANT
We, the subscribing
witnesses hereto, are personally acquainted with and subscribe our names
hereto at the request of the Declarant, an adult, whom we believe to
be of sound mind, fully aware of the action taken herein and its possible
consequence.
We, the undersigned witnesses, further declare that we are not related
to the Declarant by blood or marriage; that we are not entitled to any
portion of the estate of the Declarant upon his decease under any will
or codicil thereto presently existing or by operation of law then existing;
that we are not the attending physician, an employee of the attending
physician or a health facility in which the Declarant is a patient;
and that we are not a person who, at the present time, has a claim against
any portion of the estate of the Declarant upon his death.
_____________________________
Witness
_____________________________
Witness
STATE OF TENNESSEE
COUNTY OF DAVIDSON
Subscribed, sworn
to and acknowledged before me by _______________________________________,
Declarant, and subscribed and sworn to before me by ________________________
and ___________________________, witnesses, this _______ day of _____________,
20____.
__________________________________
NOTARY PUBLIC
MY COMMISSION EXPIRES:
__________
(Acts, 1985, ch.
355, sec 5; 1991, ch. 344, sec 6)
