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Life Sustaining Statute, Washington

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

Statutory Directive to Physicians in Conformance with Washington R.C.W. 70.122.030


Directive made this __________ day of ________________ 20________. I, ______________, being of sound mind, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below, and do hereby declare that:
(a) If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two physicians, and where the application of life-sustaining procedures would serve only to artificially prolong the moment of my death and where my physician determines that my death is imminent whether or not life-sustaining procedures are utilized, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally.
(b) In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this directive shall be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment and I accept the consequences from such refusal.
(c) If I have been diagnosed as pregnant and that diagnosis is known to my physician, this directive shall have no force or effect during the course of my pregnancy.
(d) I understand the full import of this declaration and I am emotionally and mentally competent to make this directive.

City of residence: ________________
County of residence: ______________
State of residence: _______________
Date: _____________________________

The declarer has been personally known to me and I believe him or her to be of sound mind.
Witness: __________________________________________
Witness: __________________________________________

Date: ______________________________

Statutory Directive to Physicians in Conformance with Washington R.C.W. 70.122.030
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 Washington. 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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