The declaration may be substantially in the following form, but not to the exclusion of other written and clear expressions of intent to accept, refuse, or withdraw medical care:
Terms Used In Tennessee Code 32-11-105
- Code: includes the Tennessee Code and all amendments and revisions to the code and all additions and supplements to the code. See Tennessee Code 1-3-105
- Codicil: An addition, change, or supplement to a will executed with the same formalities required for the will itself.
- Declarant: means an individual who declares a living will under this chapter. See Tennessee Code 32-11-103
- Donor: The person who makes a gift.
- health facility: means a person, facility or institution licensed or authorized to provide health or medical care. See Tennessee Code 32-11-103
- Living will: means a written declaration, pursuant to this chapter, stating declarant's desires for medical care or noncare, including palliative care, and other related matters such as organ donation and body disposal. See Tennessee Code 32-11-103
- Medical care: includes any procedure or treatment rendered by a physician or health care provider designed to diagnose, assess or treat a disease, illness or injury. See Tennessee Code 32-11-103
- Physician: means any person licensed or permitted to practice medical care under title 63, chapters 6 and 9. See Tennessee Code 32-11-103
- Terminal condition: means any disease, illness, injury or condition, including, but not limited to, a coma or persistent vegetative state, sustained by any human being, from which there is no reasonable medical expectation of recovery and that, as a medical probability, will result in the death of the human being, regardless of the use or discontinuance of medical treatment implemented for the purpose of sustaining life, or the life processes. See Tennessee Code 32-11-103
- written: includes printing, typewriting, engraving, lithography, and any other mode of representing words and letters. See Tennessee Code 1-3-105
LIVING WILL I,Â , 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 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 comfortable care or to alleviate pain. ARTIFICIALLY PROVIDED NOURISHMENT AND FLUIDS: By checking the appropriate line below, I specifically:Â Â Authorize the withholding or withdrawal of artificially provided food, water or other nourishment or fluids.Â Â DO NOT authorize the withholding or withdrawal of artificially provided food, water or other nourishment or fluids. ORGAN DONOR CERTIFICATION: Notwithstanding 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 toÂ Tennessee Code Annotated, Â§68-3-501(b) , to maintain me on artificial support systems only for the period of time required to maintain the viability of and to remove such organs and/or tissues. By checking the appropriate line below, I specifically:Â Desire to donate my organs and/or tissues for transplantation.Â Desire to donate myÂ Â Â Â Â Â (Insert specific organs and/or tissues for transplantation). Â DO NOTÂ 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,Â Tennessee Code Annotated, Â§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 Â day ofÂ , 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 the declarant’s 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 persons who, at the present time, have a claim against any portion of the estate of the declarant upon the declarant’s death. Witness Witness STATE OF TENNESSEE COUNTY OFÂ Subscribed, sworn to and acknowledged before me byÂ , the declarant, and subscribed and sworn to before me by Â andÂ , witnesses, this Â day ofÂ , 20 . Notary Public My Commission Expires:
Click to view form.