I, [Name of the declarant], 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 a terminal condition and my attending physician has determined there is no reasonable medical expectation of recovery and which, as a medical probability, will result in my death, regardless of the use or discontinuance of medical treatment implemented for the purpose of sustaining life, or the life process, I direct that medical care be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medications or the performance of any medical procedure deemed necessary to provide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 comfortable care or to alleviate pain.
ARTIFICIALLY PROVIDED NOURISHMENT AND FLUIDS:
By checking the appropriate line below, I specifically:
____ Authorize the withholding or withdrawal of artificially provided food, water or other nourishment or fluids.
____ DO NOT authorize the withholding or withdrawal of artificially provided food, water or other nourishment or fluids.
ORGAN DONOR CERTIFICATION:
Notwithstanding my previous declaration relative to the withholding or withdrawal of life-prolonging procedures, if as indicated below I have expressed my desire to donate my organs and/or tissues for transplantation, or any of them as specifically designated herein, I do direct my attending physician, if I have been determined dead according to Tennessee Code Annotated, § 68-3-501(b), to maintain me on artificial support systems only for the period of time required to maintain the viability of and to remove such organs and/or tissues. By checking the appropriate line below, I specifically:
____ Desire to donate my organs and/or tissues for transplantation.
____ Desire to donate my [Insert specific organs and/or tissues for transplantation].
____ DO NOT desire to donate my organs or tissues for transplantation.
In the absence of my ability to give directions regarding my medical care, it is my intention that this declaration shall be honored by my family and physician as the final expression of my legal right to refuse medical care and accept the consequences of such refusal.
The definitions of terms used herein shall be as set forth in the Tennessee Right to Natural Death Act, Tennessee Code Annotated, § 32-11-103.
I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration.
In acknowledgment whereof, I do hereinafter affix my signature on this the day of [Insert Date].
[Signature of Declarant]
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 the declarant’s 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 persons who, at the present time, have a claim against any portion of the estate of the declarant upon the declarant’s death.
[Signature of Witness #1]
[Signature of Witness #2]
STATE OF TENNESSEE
COUNTY OF [Name of County]
Subscribed, sworn to and acknowledged before me by[Signature of the declarant], the declarant, and subscribed and sworn to before me by [Signature of witness #1] and [Signature of witness #2], witnesses, this day of [Insert Date].
[Signature of Notary]
My Commission Expires:[Date of Expiry]