Indiana Code Title 16. Health § 16-36-4-11

Sec. 11 . The following is the life prolonging procedures will declaration form:


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 desire that if at any time I have an incurable injury, disease, or illness determined to be a terminal condition I request the use of life prolonging procedures that would extend my life.  This includes appropriate nutrition and hydration, the administration of medication, and the performance of all other medical procedures necessary to extend my life, to provide comfort care, or to alleviate pain.

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 request medical or surgical treatment and accept the consequences of the request.

I understand the full import of this declaration.




City, County, and State of Residence

The declarant has been personally known to me, and I believe (him/her) to be of sound mind.  I am competent and at least eighteen (18) years of age.

Witness __________ Date __________

Witness __________ Date __________

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