Louisiana Revised Statutes Tit. 40, § 1153.2. Illustrative form; military advance medical directives

The following is an illustrative form of a military advance medical directive suggested for use by military personnel or other eligible persons who reside in the state of Louisiana:

Title 10, United States Code, Section 1044(c)

Additionally, this form is specifically designed for use under Louisiana law. It is suggested for use by any person authorized to receive legal assistance from the military service in accordance with federal or state law, who by these presents represents and warrants that he is so eligible. Any person to whom this form is presented may conclusively rely on the authority purportedly granted hereunder.

BE IT KNOWN on this ____ day of ______, 19___, before me, an attorney authorized to render legal assistance to persons eligible for legal assistance under the provisions of 10 U.S.C. 1044 or the regulations of the Department of Defense, personally came and appeared ________________________, who declared that he is a member of the ________________________, a branch of the military designated in R.S. 40:1153.1, or is otherwise included thereunder, and did execute and sign the following declaration:

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 procedures would serve only to prolong artificially the dying process, I direct that such procedures, including hydration and sustenance, be withheld or withdrawn and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me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.

[[Optional:] In the absence of my ability to give further directions regarding the use of such life-sustaining procedures, I authorize __________________, caretaker, to make treatment decisions on my behalf and I have discussed my desires concerning terminal care with this person and I trust his/her judgment on my behalf.]

Should my caretaker be an absent person or cease or otherwise fail to act or if a caretaker has not been named in this declaration, it is my intention that this declaration 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 advance medical directive.