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Declarations
NRS 449.610 Form of declaration directing
physician to withhold or withdraw life-sustaining treatment.
A declaration directing a physician to withhold or withdraw
life-sustaining treatment may, but need not, be in the following
form:
If I should have an incurable and irreversible condition
thet, 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 direct my
attending physician, pursuant to NRS 449.535 to 449.690, inclusive,
to withold or withdraw treatment that only prolongs the process
of dying and is not necessary for my comfort or to alleviate
pain.
If you wish to includes this statement in this declaration,
you must INITIAL the statement in the box provided:
Witholding 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 _______________, 20___.
Signature:____________________________
Address:____________________________
The declarant voluntarily signed thsi writing
in my presence.
Witness:____________________________
Address:____________________________
Witness:____________________________
Address:____________________________
NRS 449.613 Form of declaration designating
another person to decide to withhold or withdraw life-sustaining
treatment. 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 server, __________________ 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 unwiling to server, 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 with to include this statement in this declaration,
you must INITIAL the statement in the box provided.
Witholding 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 _______________, 20___.
Signature:____________________________
Address:____________________________
The declarant voluntarily signed thsi writing
in my presence.
Witness:____________________________
Address:____________________________
Witness:____________________________
Address:____________________________
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 willing 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.)
You may strike out the language in the parentheses if you
do not desire it.
Withholding or withdrawal
of artificial nutrition and hydration may result in death
by starvation or dehydration. Initial this box if you want
to 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 _______________, 20___.
Signature:____________________________
Address:____________________________
The declarant voluntarily signed thsi writing
in my presence.
Witness:____________________________
Address:____________________________
Witness:____________________________
Address:____________________________
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