Rhode Island General Laws Title 23. Health and Safety § 23-4.11-3. Declaration relating to use of life sustaining procedures

(a) A competent individual eighteen (18) years of age or older may at any time execute a declaration governing the withholding or withdrawal of life sustaining procedures. The declaration must be signed by the declarant, or another at the declarant's direction in the presence of two (2) subscribing witnesses who are not related to the declarant by blood or marriage.

(b) A physician or other health care provider who is provided a copy of the declaration shall make it a part of the declarant's medical record.

(c) A declaration has operative effect only when:

(d) A declaration may, but need not, be in the following form:

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, do hereby declare:

If I should have an incurable or irreversible condition that will cause my death and if I am unable to make decisions regarding my medical treatment, I direct my attending physician to withhold or withdraw procedures that merely prolong the dying process and are not necessary to my comfort, or to alleviate pain.

This authorization includes ( ) does not include ( ) the withholding or withdrawal of artificial feeding (check only one box above). Signed this __________ day of __________, _____.

____________________ Signature

____________________ Address

The declarant is personally known to me and voluntarily signed this document in my presence.

____________________

WitnessWitness

____________________

AddressAddress