Living Will Declaration/Advance Directive of Steven Milton Dirckx
To my family, doctors, hospitals, surgeons, medical care providers, and all others concerned with my care:
I, Steven Dirckx, being of sound mind and rational thought, willfully and voluntarily make this declaration governing the use or continuation, or the withholding or withdrawal, of life-sustaining treatment should I be in a terminal condition or a permanently unconscious state and make known my desire that my dying shall not be artificially prolonged under the circumstance set forth below, do hereby declare:
1. I do not want my life to be prolonged if my physician decides that either of the following is true:
a. I am in a terminal condition which means an irreversible, incurable, and untreatable condition caused by disease, illness, or injury from which, to a reasonable degree of medical certainty as determined in accordance with reasonable medical standards by my attending physician and one other physician who as examined me from which there can be no recovery and death is likely to occur within a relatively short time if life-sustaining treatment is not administered.
b . I am in a permanently unconscious state which means a state of permanent unconsciousness that, to a reasonable degree of medical certainty as determined in accordance with reasonable medical standards by my attending physician and one other physician who has examined me, is characterized by both an irreversible unawareness of one's being and environment and total loss of cerebral cortical functioning, resulting my having no capacity to experience pain or suffering.
2. Artificial nutrition and hydration should not be provided, or should be stopped, based on the other life-sustaining treatment choice I have made in statement (1) above.
I authorize my attending physician to withhold or withdraw nutrition or hydration when I am in a permanently unconscious state and when the nutrition and hydration will not or no longer serve to provide comfort to me or alleviate my pain and if my attending physician and at least one other physician who has examined me determines, to a reasonable degree of medical certainty and in accordance with reasonable medical standards, that nutrition or hydration will not or no longer will serve to provide comfort to me or alleviate my pain.
In the absence of my ability to give directions regarding the use of such life-sustaining treatment, it is my intention that this declaration shall be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences of such refusal.
I have the right to revoke this declaration at any time and in any manner.
3. I want to make an anatomical gift according to the following.
Upon my death, the following are my directions regarding donation of all or part of my body:
In the hope that I may help others upon my death, I hereby donate all of my organs and tissues for any purpose authorized by law: Transplantation, therapy, research, or education.
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