Living Will Sample Form

A declaration may, but need not be, in the following form:

STATE OF RHODE ISLAND
CHAPTER 23-4.11
RIGHTS OF THE TERMINALLY ILL ACT

DECLARATION

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, so hereby declare:

If I should have an incurable or irreversible condition that will cause my death within a relatively short time, and if I am unable to make decisions regarding my medical treatment, I direct my attending physician to withhold or withdraw procedures that merely prolong the dying process and are not necessary to my comfort, or to alleviate pain.

the withholding or withdrawal of artificial feeding. (check only one box above)

Signed this ________________ day of ________________, _______.

___________________________________
Signature of Declarant

___________________________________
Address

The declarant is personally known to me and voluntarily signed this document in my presence.  I am not related to the declarant by blood or marriage.

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