A declaration may, but need not be, in the following form:

STATE OF RHODE ISLAND
CHAPTER 23-4.11
RIGHTS OF THE TERMINALLY ILL ACT

DECLARATION

I, _____________________________, being of sound mind willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, so hereby declare:

If I should have an incurable or irreversible condition that will cause my death within a relatively short time, and if I am unable to make decisions regarding my medical treatment, I direct my attending physician to withhold or withdraw procedures that merely prolong the dying process and are not necessary to my comfort, or to alleviate pain.

 

This authorization

includes [ ]

  does not include [ ]

the withholding or withdrawal of artificial feeding. (check only one box above)

 

Signed this ________________ day of ________________, _______.

___________________________________
Signature of Declarant

___________________________________
Address

 

The declarant is personally known to me and voluntarily signed this document in my presence.  I am not related to the declarant by blood or marriage.

_______________________
Witness

__________________________ 
Address

   
_______________________
Witness

__________________________
Address

 

 

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