Form of declaration designating another person to decide to withhold or withdraw life-sustaining treatment.
1. A declaration that designates another person to make decisions governing the withholding or withdrawal of life-sustaining treatment may, but need not, be in the following form:
If I should have an incurable and irreversible condition that, without the administration of life-sustaining treatment, will, in the opinion of my attending physician, cause my death within a relatively short time, and I am no longer able to make decisions regarding my medical treatment, I appoint ............................... or, if he or she is not reasonably available or is unwilling to serve, .............................., to make decisions on my behalf regarding withholding or withdrawal of treatment that only prolongs the process of dying and is not necessary for my comfort or to alleviate pain, pursuant to NRS 449.535 to 449.690, inclusive. (If the person or persons I have so appointed are not reasonably available or are unwilling to serve, I direct my attending physician, pursuant to those sections, to withhold or withdraw treatment that only prolongs the process of dying and is not necessary for my comfort or to alleviate pain.)
Strike language in parentheses if you do not desire it.
If you wish to include this statement in this declaration, you must INITIAL the statement in the 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 way of the gastro-intestinal tract after all other treatment is withheld pursuant to this declaration.
[............................................ ]
Signed this ........………...... day of ..…..........., ......
Signature..........................................................
Address............................................................
The declarant voluntarily signed this writing in my presence.
Witness............................................................
Address............................................................
Witness............................................................
Address............................................................
Name and address of each designee.
Name.................................................................
Address............................................................
2. The designation of an attorney-in-fact pursuant to NRS 111.460 or 449.800 to 449.860, inclusive, or the judicial appointment of a guardian, who is authorized to make decisions regarding the withholding or withdrawal of life-sustaining treatment, constitutes for the purpose of NRS 449.535 to 449.690, inclusive, a declaration designating another person to act for the declarant pursuant to subsection 1.
Last modified: February 26, 2006