Louisiana Living Will Declaration

LOUISIANA LIVING WILL DECLARATION
(La. R.S. 40:1151.2)

Declaration made this ______ day of _____________________ (month, year).

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 and do hereby declare:

If at any time I should have an incurable injury, disease or illness, or be in a continual profound comatose state with no reasonable chance of recovery, certified to be a terminal and irreversible condition by two physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life-sustaining procedures are utilized and where the application of life-sustaining procedure would serve only to prolong artificially the dying process, I direct (initial one only):

_____ That all life-sustaining procedures, including nutrition and hydration, be withheld or withdrawn so that food and water will not be administered invasively.

_____ That life-sustaining procedures, except nutrition and hydration, be withheld or withdrawn so that food and water can be administered invasively.

I further direct that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care.

In the absence of my ability to give directions regarding the use of such life-sustaining procedures, 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 from such refusal.

I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration.

__________________________________________
Signature of Person Making Declaration (Declarant)

__________________________________________
(Type or Print Name of Declarant)

____________________
Date of Birth

__________________________________________
Street Address

__________________________________________
City, State, Zip Code       

____________________
Parish

The declarant has been personally known to me and I believe him or her to be of sound mind.

__________________________________________
Signature of First Witness

__________________________________________
(Type or Print Name of First Witness)

____________________
Date of Birth

__________________________________________
Street Address

__________________________________________
City, State, Zip Code       

____________________
Parish

__________________________________________
Signature of Second Witness

__________________________________________
(Type or Print Name of Second Witness)

____________________
Date of Birth

__________________________________________
Street Address

__________________________________________
City, State, Zip Code       

____________________
Parish

"LIVING WILL" DECLARATION STATE REGISTRATION

INSTRUCTIONS: The Secretary of State's office maintains a "Living Will" declaration registry. The state accepts the original, a multiple original, or a certified copy of the declaration, either from the declarant or attorney. Once filed, a laminated wallet ID card and an engraved "Do Not Resuscitate" bracelet are provided to the declarant, indicating that the "Living Will" declaration is on file with the state registry. The state will provide a copy of the declaration when requested by any attending physician or health care facility. The fee to register a declaration is $20; the fee to file a notice of revocation of a declaration is $5. A certified copy of a living will declaration is $10. Mail the Living Will Declaration and filing fee, payable to the "Louisiana Secretary of State" in the form of a personal check or money order to: Louisiana Secretary of State, Publications Division, P.O. Box 94125, Baton Rouge, LA 70804-9125. Direct any questions regarding this this registration service to the Secretary of State's office on (225) 922-0900.