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LIVING WILL - F1DPA5: This is a living will, drafted in accordance with La. R.S. 40:1299.58.3 as amended by Act 447 of 2005. Act No. 447 of 2005 added a definition for “spouse” and amended the illustrative form to give the Declarant a choice of whether or not to have food and water administered invasively. Previously, the illustrative form did not include such a choice but simply directed that “life-sustaining procedures …be withheld or withdrawn”. NOTE: The definition of “life-sustaining procedure” was not changed. Before and after Act No. 447 the definition of “life-sustaining procedure” included “such procedures as the invasive administration of nutrition and hydration”(emphasis added). Furthermore, Act No. 447 added paragraph (3) (b) to La .R.S. 40:1299.58.3(C). This paragraph provides: “Any declaration executed prior to August 15, 2005, which does not contain an option to specifically initial a choice regarding nutrition and hydration shall not be invalid for that reason nor presumed to mean that the declarant desires the invasive administration of nutrition or hydration.” CAVEAT: In light of this new provision, it would be advisable to alert clients who previously signed the illustrative form about these changes in the event that they, like many, did not consider the intravenous administration of food and water to be “life-sustaining procedures”. As allowed by La. R.S. 40:1299.58.3(C), the declaration may designate an agent to make treatment decisions should the declarant be diagnosed as terminally ill and be comatose, incompetent, or incapable of communication. For provisions dealing with notice on driver's license, see La. R.S. 32:410(C). * * * * * * * DECLARATION Declaration made this [_day_] day of [_Month_], [_Year_]. I, [_DECLARANT_], being of sound mind, 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 an incurable injury, disease or illness, or be in a continual profound comatose state with no reasonable chance of recovery, certified to be a terminal and irreversible condition by two physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life-sustaining procedures are utilized and where the application of life-sustaining procedures would serve only to prolong artificially the dying process, I direct (initial one only): _____That all life-sustaining procedures, including nutrition and hydration, be withheld or withdrawn so that food and water will not be administered invasively. _____That life-sustaining procedures, except nutrition and hydration, be withheld or withdrawn so that food and water can be administered invasively. I further direct 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.


In the absence of my ability to give directions regarding the use of such lifesustaining procedures, it is my intention that this declaration shall be honored by my family and physician(s) 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: ___________________________________ [_DECLARANT_] ________________________________________ [_City, Parish, State_] The declarant has been personally known to me and I believe [_him_her_] to be of sound mind. Witness: __________________________________ [_WITNESS_1_] Witness: __________________________________ [_WITNESS_2_] ********** WORD KEY: EXPLANATION: [_day_] [_Month_] [_Year_] Day, month and year of declaration. [_DECLARANT_] Full name of declarant. [_AGENT_] Full name of person authorized by declaration to make medical decisions. [_DECLARANT_] Full name of declarant. [_him_her_] As appropriate. [_City, Parish, State_] [_WITNESS_1_] [_WITNESS_2_]

City, Parish, State of Residence

Name of first witness. Name of second witness.


F1dpa5 living will