Statutory Declaration in Conformance with Virginia Natural Death Act VA. Code Section 54-325.8:4
DECLARATION OF ___________________
Declaration 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, do declare:
If at any time I should have a terminal condition and my attending physician has determined that there can be no recovery from such condition and my death will is imminent, 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procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me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 or to alleviate pain.
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 physician 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.
Signed: _______________________________________
City of residence: ______________
County of residence: ____________
State of residence: _____________
Date: _____________________
The Declarant is known to me and I believe him or her to be of sound mind.
Witness: _________________________________________________
Witness: _________________________________________________
Date: ___________________
Statutory Declaration in Conformance with Virginia Natural Death Act VA. Code Section 54-325.8:4
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 Virginia. 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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