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Life Sustaining Statute, Kansas

Free Printable Life Sustaining Statute, Kansas FormFree Printable Life Sustaining Statute, Kansas Form

Statutory Declaration in Conformance with Kansas Natural Death Act, Kansas Statutes Section 65-28,103
DECLARATION OF ___________________

Declaration made this __________ day of ________________ 20_____. 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procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me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 physicians 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.


City of residence: _________________
County of residence: _______________
State of residence: ________________
The Declarant has been personally known to me and I believe him or her to be of sound mind. I did not sign the Declarant’s signature above for or at the declaration 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 in testate succession or under any will of Declarant or codicil thereto, or directly financially responsible for Declarant’s medical care.

Witness _________________________________________________

Witness _________________________________________________

Date: _______________
Statutory Declaration in Conformance with Kansas Natural Death Act, Kansas Statutes Section 65-28,103
Review List

This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in Kansas. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1. Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.


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