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Living Will As Provided By Tennessee Code 32-11-105 - Version 1

Living will as provided by Tennessee Code Annotated 32-11-105. Includes terms for organ donation as well as explicit terms for artificially provided nourishment and fluids.

LIVING WILL OF Please state the name of the declarant

I, Please state the name of the declarant, willfully and voluntarily make known my desires 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 that there can be no recovery from such condition and my death is imminent, and where the application of life-prolonging procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medications or the performance of any medical procedure deemed necessary to provide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 physicians 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. In acknowledgement whereof, I do hereinafter

affix my signature on this the ___________ day of ______________

19___________.

_____________________________________________________________ Declarant- Please state the name of the declarant

Residing at : Please state the city of the declarant's residence

Please state the state of the declarant's residence

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 his 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 a person who, at the present time, has a claim against any portion of the estate of the declarant upon his death.

Witness ______________________________________________

Witness _______________________________________________

Subscribed, sworn to and acknowledged before me by Please state the name of the declarant, the declarant, and subscribed to before me

by __________________________ and _____________________________,

witnesses, this _______ day of ___________________________ 19___.

_______________________________________________________________

Notary Public