Indiana Code Title 16. Health § 16-36-4-10

Sec. 10. The following is the living will declaration form:

LIVING WILL DECLARATION

Declaration made this __________ day of __________ (month, year).  I, __________, being at least eighteen (18) years of age and of sound mind, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below, and I declare:

If at any time my attending physician certifies in writing that:  (1) I have an incurable injury, disease, or illness;  (2) my death will occur within a short time;  and (3) the use of life prolonging procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the performance or provision of any medical procedure or medication necessary to provide me with comfort care or to alleviate pain, and, if I have so indicated below, the provision of artificially supplied nutrition and hydration.  (Indicate your choice by initialing or making your mark before signing this declaration):

__________I wish to receive artificially supplied nutrition and hydration, even if the effort to sustain life is futile or excessively burdensome to me.

__________I do not wish to receive artificially supplied nutrition and hydration, if the effort to sustain life is futile or excessively burdensome to me.

__________ I intentionally make no decision concerning artificially supplied nutrition and hydration, leaving the decision to my health care representative appointed under IC 16-36-1-7 or my attorney in fact with health care powers appointed under IC 30-5-5-16.

In the absence of my ability to give directions regarding the use of life prolonging procedures, it is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences of the refusal.

I understand the full import of this declaration.

The declarant has been personally known to me, and I believe (him/her) to be of sound mind.  I did not sign the declarant's signature above for or at the direction of the declarant.  I am not a parent, spouse, or child of the declarant.  I am not entitled to any part of the declarant's estate or directly financially responsible for the declarant's medical care.  I am competent and at least eighteen (18) years of age.

Witness ______________________________ Date ______________________________

Witness ______________________________ Date ______________________________