Louisiana Living Will Declaration Form
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STATE OF LOUISIANA
DECLARATION
Declaration made this ________day of _______________, __________ (month, year).
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 procedure
would serve only to prolong artificially the dying process, I direct (initial one only):
_______ That all life-sustaining procedures, including nutrition and hydration, be withheld