Directive to physicians as provided by california.
HEALTH AND SAFETY CODE SECTION 7187
DIRECTIVE TO PHYSICIANS
Directive made this _________________ day of ___________.
I, State the name of the declarant, being of sound mind, willfully and voluntarily make known my desire that my life shall not be artificially prolonged under
the circumstances set forth below, do hereby declare:
1. If at any time I should have an incurable injury, disease,
or illness certified to be a terminal condition by two
physicians, and where the application of life-sustaining
procedures would serve only to artificially prolong the moment
of my death and where my physician determines that my death
is imminent whether or not life-sustaining procedures are
utilized, I direct that such procedures be withheld or
withdrawn, and that I be permitted to die naturally,
2. In the absence of my ability to give directions regarding
the use of such life-sustaining procedures, it is my intention
that this directive 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
3. If I have been diagnosed as pregnant and that diagnosis is
known to my physician, this directive shall have no force or
effect during the course of my pregnancy.
4. I have been diagnosed and notified at least 14 days ago as
having a terminal condition by State Dr.'s name (terminal diagnosis only), M.D. whose address is State Dr.'s City, State of office (terminal only).
I understand that if I have not filed in the physicians name and
address, it shall be presumed that I did not have a terminal
condition when I made out this directive.
5. This directive shall have no force and effect five years
from the date filled in above.
6. I understand the full import of this directive and I am
emotionally and mentally competent to make this directive.
State the name of the declarant
The declarant has been personally known to me and
I believe him or her to be of sound mind.