Declaration in conformance with missouri statutes 459.015.
I have the primary right to make my own decisions concerning treatment that might unduly prolong the dying process. By this declaration I express to my physician, family and friends my intent. If I should have a terminal condition it is my desire that my dying not be prolonged by administration of death-prolonging procedures. If my condition is terminal and I am unable to participate in decisions regarding my medical treatment, I direct that my attending physician to withhold or withdraw medical procedures that merely prolong the dying process and are not necessary to my comfort or to alleviate pain. It is not my intent to authorize affirmative or deliberate acts or omissions to shorten my life rather only to permit the natural process of dying.
Signed this ____________________ day of ________________
Signature- Please state the name of the declarant
City of residence: Please state the city where signed County of residence: Please state the county where signed State of residence: Please state the state where signed
The declarant is known to me, is eighteen years of age or older, of sound mind and voluntarily signed this document in my presence.