2009 Kentucky Revised Statutes CHAPTER 311 PHYSICIANS, OSTEOPATHS, PODIATRISTS, AND RELATED MEDICAL PRACTITIONERS 311.625 Form of living will directive.
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311.625 Form of living will directive.
(1) A living will directive made pursuant to KRS 311.623 shall be substantially in the
following form, and may include other specific directions which are in accordance <br>with accepted medical practice and not specifically prohibited by any other statute. <br>If any other specific directions are held by a court of appropriate jurisdiction to be <br>invalid, that invalidity shall not affect the directive.
"Living Will Directive
My wishes regarding life-prolonging treatment and artificially provided nutrition and <br>hydration to be provided to me if I no longer have decisional capacity, have a terminal <br>condition, or become permanently unconscious have been indicated by checking and <br>initialing the appropriate lines below. By checking and initialing the appropriate lines, I <br>specifically: <br>.... Designate ........................ as my health care surrogate(s) to make health care decisions <br>for me in accordance with this directive when I no longer have decisional capacity. If <br>............................. refuses or is not able to act for me, I designate .............................. as <br>my health care surrogate(s). <br>Any prior designation is revoked. <br>If I do not designate a surrogate, the following are my directions to my attending <br>physician. If I have designated a surrogate, my surrogate shall comply with my wishes as <br>indicated below: <br>.... Direct that treatment be withheld or withdrawn, and that I be permitted to die naturally <br>with only the administration of medication or the performance of any medical treatment <br>deemed necessary to alleviate pain. <br>.... DO NOT authorize that life-prolonging treatment be withheld or withdrawn. <br>.... Authorize the withholding or withdrawal of artificially provided food, water, or other <br>artificially provided nourishment or fluids. <br>.... DO NOT authorize the withholding or withdrawal of artificially provided food, water, <br>or other artificially provided nourishment or fluids. <br>.... Authorize my surrogate, designated above, to withhold or withdraw artificially <br>provided nourishment or fluids, or other treatment if the surrogate determines that <br>withholding or withdrawing is in my best interest; but I do not mandate that withholding <br>or withdrawing. <br>.... Authorize the giving of all or any part of my body upon death for any purpose <br>specified in KRS 311.1929. <br>.... DO NOT authorize the giving of all or any part of my body upon death. <br>In the absence of my ability to give directions regarding the use of life-prolonging <br>treatment and artificially provided nutrition and hydration, it is my intention that this <br>directive shall be honored by my attending physician, my family, and any surrogate <br>designated pursuant to this directive as the final expression of my legal right to refuse <br>medical or surgical treatment and I accept the consequences of the refusal. <br>If I have been diagnosed as pregnant and that diagnosis is known to my attending <br>physician, this directive shall have no force or effect during the course of my pregnancy.
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I understand the full import of this directive and I am emotionally and mentally <br>competent to make this directive. <br>Signed this .... day of .........., 19... <br>
Signature and address of the grantor.
In our joint presence, the grantor, who is of sound mind and eighteen (18) years of age, or <br>older, voluntarily dated and signed this writing or directed it to be dated and signed for <br>the grantor. <br>
Signature and address of witness.
Signature and address of witness.
OR <br>STATE OF KENTUCKY) <br>...........County) <br>Before me, the undersigned authority, came the grantor who is of sound mind and <br>eighteen (18) years of age, or older, and acknowledged that he voluntarily dated and <br>signed this writing or directed it to be signed and dated as above. <br>Done this .... day of ........, 19... <br>
Signature of Notary Public or other officer.
Date commission expires:.............
Execution of this document restricts withholding and withdrawing of some medical <br>procedures. Consult Kentucky Revised Statutes or your attorney." <br>(2) An advance directive shall be in writing, dated, and signed by the grantor, or at the
grantor's direction, and either witnessed by two (2) or more adults in the presence of <br>the grantor and in the presence of each other, or acknowledged before a notary <br>public or other person authorized to administer oaths. None of the following shall <br>be a witness to or serve as a notary public or other person authorized to administer <br>oaths in regard to any advance directive made under this section: <br>(a) A blood relative of the grantor; <br>(b) A beneficiary of the grantor under descent and distribution statutes of the
Commonwealth;
(c) An employee of a health care facility in which the grantor is a patient, unless
the employee serves as a notary public;
(d) An attending physician of the grantor; or <br>(e) Any person directly financially responsible for the grantor's health care.
(3) A person designated as a surrogate pursuant to an advance directive may resign at
any time by giving written notice to the grantor; to the immediate successor <br>surrogate, if any; to the attending physician; and to any health care facility which is <br>then waiting for the surrogate to make a health care decision.
(4) An employee, owner, director, or officer of a health care facility where the grantor
is a resident or patient shall not be designated or act as surrogate unless related to <br>the grantor within the fourth degree of consanguinity or affinity or a member of the <br>same religious order.
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Effective: July 15, 2010 <br>History: Amended 2010 Ky. Acts ch. 161, sec. 31, effective July 15, 2010. -- Amended
1998 Ky. Acts ch. 370, sec. 8, effective July 15, 1998; and ch. 392, sec. 2, effective <br>July 15, 1998. -- Created 1994 Ky. Acts ch. 235, sec. 3, effective July 15, 1994.
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