Declaration made this   day of  ,   (year)  , I,   , willfully and voluntarily make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do hereby declare that, if at any time I am incapacitated and
(initial)   I have a terminal condition
or   (initial)   I have an end-stage condition
or   (initial)   I am in a persistent vegetative state
and if my primary physician and another consulting physician have determined that there is no reasonable medical probability of my recovery from such condition, I direct that life-prolonging procedures be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only the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 or to alleviate pain.
It is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences for such refusal.
In the event that I have been determined to be unable to provide express and informed consent regarding the withholding, withdrawal, or continuation of life-prolonging procedures, I wish to designate, as my surrogate to carry out the provisions of this declaration:
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I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration.
Additional Instructions (optional):
Terms Used In This Law
- end-stage condition: means an irreversible condition that is caused by injury, disease, or illness which has resulted in progressively severe and permanent deterioration, and which, to a reasonable degree of medical probability, treatment of the condition would be ineffective. See Florida Statutes 765.101
- informed consent: means consent voluntarily given by a person after a sufficient explanation and disclosure of the subject matter involved to enable that person to have a general understanding of the treatment or procedure and the medically acceptable alternatives, including the substantial risks and hazards inherent in the proposed treatment or procedures, and to make a knowing health care decision without coercion or undue influence. See Florida Statutes 765.101
- persistent vegetative state: means a permanent and irreversible condition of unconsciousness in which there is:(a) The absence of voluntary action or cognitive behavior of any kind. See Florida Statutes 765.101
- physician: means a person licensed pursuant to chapter 458 or chapter 459. See Florida Statutes 765.101
- primary physician: means a physician designated by an individual or the individual's surrogate, proxy, or agent under a durable power of attorney as provided in chapter 709, to have primary responsibility for the individual's health care or, in the absence of a designation or if the designated physician is not reasonably available, a physician who undertakes the responsibility. See Florida Statutes 765.101
- principal: means a competent adult executing an advance directive and on whose behalf health care decisions are to be made or health care information is to be received, or both. See Florida Statutes 765.101
- surrogate: means any competent adult expressly designated by a principal to make health care decisions and to receive health information. See Florida Statutes 765.101
- terminal condition: means a condition caused by injury, disease, or illness from which there is no reasonable medical probability of recovery and which, without treatment, can be expected to cause death. See Florida Statutes 765.101