Tennessee Statutory Living Will
I, __________________, 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 a terminal condition and my attending
physician has determined there is no reasonable medical expectation of recovery
and which, as a medical probability, will result in my death, regardless of the
use or discontinuance of medical treatment implemented for the purpose of
sustaining life, or the life process, I direct that medical care be withheld or
withdrawn, and that I be permitted to die naturally with only the administration
of medications or the performance of any medical procedure deemed necessary to
provide me with comfortable care or to alleviate pain.
ARTIFICIALLY PROVIDED NOURISHMENT AND FLUIDS:
By checking the appropriate line below, I specifically:
______ Authorize the withholding or withdrawal of artificially provided
food, water or other nourishment or fluids.
______ DO NOT authorize the withholding or withdrawal of artificially
provided food, water or other nourishment or fluids.
ORGAN DONOR CERTIFICATION:
Notwithstanding my previous declaration relative to the withholding or
withdrawal of life-prolonging procedures, if as indicated below I have expressed
my desire to donate my organs and/or tissues for transplantation, or any of them
as specifically designated herein, I do direct my attending physician, if I have
been determined dead according to Tennessee Code Annotated, § 68-3-501(b), to
maintain me on artificial support systems only for the period of time required
to maintain the viability of and to remove such organs and/or tissues.
By checking the appropriate line below, I specifically:
______ Desire to donate my organs and/or tissues for transplantation.
______ Desire to donate my _____________________________________________.
(Insert specific organs and/or tissues for transplantation)
______ DO NOT desire to donate my organs or tissues for transplantation.
In the absence of my ability to give directions regarding my medical care, it
is my intention that this declaration shall be honored by my family and
physician as the final expression of my legal right to refuse medical care and
accept the consequences of such refusal.
The definitions of terms used herein shall be as set forth in the Tennessee
Right to Natural Death Act, Tennessee Code Annotated, § 32-11-103.
I understand the full import of this declaration, and I am emotionally and
mentally competent to make this declaration.
In acknowledgment whereof, I do hereinafter affix my signature on this the
______ day of ________, 20____.
__________________________________
Signature of Declarant
We, the subscribing witnesses hereto, are personally acquainted with and
subscribe our names hereto at the request of the declarant, an adult, whom we
believe to be of sound mind, fully aware of the action taken herein and its
possible consequence.
We, the undersigned witnesses, further declare that we are not related to
the declarant by blood or marriage; that we are not entitled to any portion of
the estate of the declarant upon the declarant's decease under any will or
codicil thereto presently existing or by operation of law then existing; that we
are not the attending physician, an employee of the attending physician or a
health facility in which the declarant is a patient; and that we are not persons
who, at the present time, have a claim against any portion of the estate of the
declarant upon the declarant's death.
______________________________________
Witness
______________________________________
Witness
STATE OF TENNESSEE
COUNTY OF __________________
Subscribed, sworn to and acknowledged before me by ____________, the
declarant, and subscribed and sworn to before me by ________ and ________,
witnesses, this ______ day of ____________, 20____.
_______________________________________
Notary Public
My Commission Expires: __________________________