Declaration – Directive to Physician
If I should have an incurable and irreversible condition that , without the administration of life-sustaining treatment , will , in the opinion of my attending doctor , cause my death within a relatively short time , and I am no longer able to make decisions regarding my medical treatment , I direct my attending doctor , pursuant to NRS 449.535 to 449.690 inclusive , to withhold or withdraw my treatment that only prolongs the process of dying and is not necessary for my comfort or to alleviate pain .
If you wish to include this statement in this declaration , you must initial the statement box provided :
☐Withholding or withdrawal of artificial nutrition and hydration may result in death by starvation or dehydration . Initial this box if you want to receive or continue receiving artificial nutrition and hydration by the way of the gastro-intestinal tract after all other treatment is withheld pursuant to this declaration .
Signed this ______________ day of ______________________________, _______________ Signature : ____________________________________
Address : ____________________________________ ____________________________________
This declarant voluntarily signed this writing in my presence .
Signature :____________________________________ Address :____________________________________
____________________________________
Signature :____________________________________ Address :____________________________________
____________________________________
( Added to NRS by 1977,760 ; A 1991 , 633 ; 1993 , 2790 )
-11-