Declaration
DISTRICT OF COLUMBIA DECLARATION Declaration made on the information supplied in the interview. I, the information supplied in the interview, being of sound mind, voluntarily make known my desire that my dying not be artificially prolonged under the conditions stated below. If I have an incurable injury, disease, or illness certified as a terminal condition by two physicians who have personally examined me, one of whom is my attending physician, and they determine that death will occur whether or not life-sustaining procedures are used and those procedures would only artificially prolong dying, I direct that life-sustaining procedures be withheld or withdrawn. I direct that medication and medical procedures needed for comfort care and relief of pain continue. I intend this Declaration to be honored as the final expression of my right to refuse medical or surgical treatment if I cannot give directions myself. Additional treatment directions: the information supplied in the interview I understand the significance of this Declaration and make it voluntarily. Signature: Date: the information supplied in the interview Address: the information supplied in the interview Witnesses Each witness states that the declarant is personally known or satisfactorily identified, appears to be of sound mind, and that the witness satisfies the exclusions in D.C. Code § 7-622, including the restrictions concerning relationship, estate interest, financial responsibility for care, and the attending physician. Witness 1: Date: Witness 2: Date: This document does not appoint a health-care agent and does not create a D.C. MOST or other clinician medical order.