Declarationmadethis Dayof 2 ,I

Living Will

Declarationmadethis dayof 2 ,I willfullyandvoluntarilymakeknownmydesirethatmydyingnotbeartificiallyprolongedunderthecircumstances setforthbelow,andIdoherebydeclarethat,ifat anytime Iamincapacitatedand

Ihave a terminalcondition.

or Ihaveanendstagecondition.

or Iamin a persistentvegetativestate,

andifmyattendingortreatingphysicianandanotherconsultingphysicianhavedeterminedthatthereisnoreasonable medicalprobabilityofmyrecoveryfromsuchcondition,Idirectthatlife-prolonging proceduresbewithheldor withdrawnwhentheapplicationofsuchprocedureswouldserveonlytoprolongartificiallytheprocessofdying,and thatIbepermittedtodienaturallywithonlytheadministrationofmedication ortheperformanceofanymedical proceduredeemednecessarytoprovidemewithcomfortcareortoalleviatepain.

Itismyintentionthatthisdeclarationbehonoredbymyfamilyandphysicianasthefinalexpressionofmylegalright torefusemedicalorsurgicaltreatmentandtoaccepttheconsequencesforsuchrefusal.

IntheeventthatIhavebeendeterminedtobeunabletoprovideexpressandinformed consentregardingthe withholding,withdrawal,orcontinuationoflife-prolongingprocedures,Iwishtodesignate,asmysurrogatetocarry outtheprovisionsofthisdeclaration:

Name

Address

City State Zip

Phone

Iunderstandthefullimportofthisdeclaration,andIamemotionallyandmentallycompetentto makethis

declaration.
AdditionalInstructions(optional):
(Signed):
Witness
StreetAddress
City, StateZip
Phone / Witness
StreetAddress
City, StateZip
Phone

Theprincipal’sfailuretodesignateasurrogateshallnotinvalidatetheliving will.

—ThisformofferedasacourtesyofTheFloridaBarandtheFloridaMedicalAssociation—

04/05

LIVINGWILLSANDHEALTHCAREADVANCEDIRECTIVES:FAQs

TheFloridaLegislaturehasrecognizedthateverycompetentadulthasthefundamental rightofself- determination regardingdecisionspertainingtohisorherownhealth,includingtherighttochooseor refusemedicaltreatmentorprocedureswhichwouldonlyprolonglifewhenaterminalconditionexists.This right,however,issubjecttocertaininterestsofsociety,suchastheprotection ofhumanlifeandthe preservationofethicalstandardsinthemedicalprofession. Toensurethatthisrightisnotlostor diminishedbyvirtueoflaterphysicalormentalincapacity,theLegislaturehasestablishedaprocedure withinFloridaStatutesChapter765allowingapersonto planforincapacity,andifdesired,to designate anotherpersontoactonhisorherbehalfandmakenecessarymedicaldecisionsuponsuchincapacity.

WhatisaLivingWill?

Everycompetentadulthastherighttomakeawrittendeclarationcommonlyknownasa"LivingWill."The purposeofthisdocument istodirecttheprovision, thewithholdingorwithdrawal oflifeprolonging proceduresintheeventoneshouldhaveaterminalcondition.Thesuggestedformofthisinstrumenthas beenprovidedbytheLegislaturewithinFloridaStatutesSection765.303.InFlorida,thedefinitionof"life prolongingprocedures"hasbeenexpandedbytheLegislaturetoincludetheprovisionoffoodandwater toterminallyillpatients.

WhatisthedifferencebetweenaLivingWillandalegalwill?

ALivingWillshouldnotbeconfusedwithaperson’slegalwill,whichdisposesofpersonalpropertyonor afterhisorherdeath,andappointsapersonalrepresentativeorrevokesorrevisesanotherwill.

HowdoI makemyLivingWilleffective?

UnderFloridalaw,aLivingWillmustbesignedbyitsmakerinthepresenceoftwowitnesses,atleastone ofwhomisneitherthespousenorabloodrelativeofthemaker.If themakerisphysicallyunabletosign theLivingWill,oneofthewitnessescansigninthepresenceandatthedirectionofthemaker.Floridawill recognizeaLivingWill,whichhasbeensignedinanotherstate,ifthatLivingWillwassignedincompliance withthelawsofthatstate,orincompliancewiththelawsofFlorida.

AfterI signaLivingWill,whatisnext?

OnceaLivingWillhasbeensigned,itisthemaker'sresponsibilitytoprovidenotificationtothephysician ofitsexistence.ItisagoodideatoprovideacopyoftheLivingWilltothemaker'sphysicianandhospital, tobeplacedwithinthemedicalrecords.

WhatisaHealthCareSurrogate?

Anycompetent adultmayalsodesignateauthoritytoaHealthCareSurrogatetomakeallhealthcare decisionsduringanyperiodofincapacity.Duringthemaker'sincapacity,theHealthCareSurrogatehas thedutytoconsultexpeditiously, withappropriatehealthcareproviders.TheSurrogatealsoprovides informedconsentandmakesonlyhealthcaredecisionsforthemaker,whichheorshebelievesthemaker wouldhavemadeunderthecircumstancesifthemakerwerecapableofmakingsuchdecisions.If there isnoindication ofwhatthemakerwouldhavechosen,theSurrogate mayconsiderthemaker'sbest interestindecidingonacourseoftreatment.Thesuggestedformofthisinstrumenthasbeenprovidedby theLegislaturewithinFloridaStatutesSection765.203.

HowdoI designateaHealthCareSurrogate?

UnderFloridalaw,designationofaHealthCareSurrogateshouldbemadethroughawrittendocument, andshouldbesignedinthepresenceoftwowitnesses,atleastoneofwhomisneitherthespousenora bloodrelativeofthemaker.ThepersondesignatedasSurrogatecannotactasawitnesstothesigningof thedocument.

CanI havemorethanoneHealthCareSurrogate?

ThemakercanalsoexplicitlydesignateanAlternateSurrogate.TheAlternateSurrogatemayassumethe dutiesasSurrogateiftheoriginalSurrogateisunwillingorunabletoperformhisorherduties.Ifthemaker isphysicallyunabletosignthedesignation, heorshemay,inthepresenceofwitnesses,directthat anotherpersonsignthedocument.AnexactcopyofthedesignationmustbeprovidedtotheHealthCare Surrogate.Unlessthe designationstatesatimeoftermination,the designationwill remainineffectuntil revokedbyitsmaker.

CantheLivingWillandtheHealthCareSurrogatedesignationberevoked?

BoththeLivingWill and theDesignationofHealthCareSurrogatemay berevokedbythemakeratany timebyasignedanddatedletterofrevocation;byphysicallycancelingordestroyingtheoriginaldocument; byanoralexpression ofone'sintenttorevoke;orbymeansofalaterexecuteddocumentwhichis materiallydifferentfromtheformerdocument.Itisveryimportanttotelltheattendingphysicianthatthe LivingWillandDesignationofHealthCareSurrogatehasbeenrevoked.

WherecanI gotoobtainlegaladviceonthisissue?

Ifyoubelieveyouneedlegaladvice,callyourattorney.Ifyoudonothaveanattorney,callTheFloridaBar LawyerReferralServiceat1-800-342-8011,orthelocallawyerreferralserviceorlegalaidofficelistedin theyellowpagesofyourtelephonebook.

Thisinformationhasbeenprepared by the Consumer ProtectionLawCommittee of The Florida BarandtheBar’sPublicInformationOfficeandisofferedasacourtesyofTheFloridaBarandthe Florida Medical Association.