Declaration in Conformance with Missouri Statutes 459.015
I have the primary right to make my own decisions concerning treatment that might unduly prolong the dying process. By this declaration I express to my physician, family and friends my intent. If I should have a terminal condition it is my desire that my dying not be prolonged by administration of death-prolonging procedures. If my condition is terminal and I am unable to participate in decisions regarding my medical treatment, I direct that my attending physician to withhold or withdraw medical procedures that merely prolong the dying process and are not necessary to my comfort or to alleviate pain. It is not my intent to authorize affirmative or deliberate acts or omissions to shorten my life rather only to permit the natural process of dying.
Signed this ____________________ day of _______________
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Signature: __________________
City of residence: __________
County of residence: ________
State of residence: _________
The Declarant is known to me, is eighteen years of age or older, of sound mind and voluntarily signed this document in my presence.
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Witness
Address:
________________________________________________________________
Witness
Address:
Declaration in Conformance with Missouri Statutes 459.015
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 Missouri. 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.
- 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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