2014 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 with accepted medical practice and not specifically prohibited by
any other statute. If any other specific directions are held by a court of
appropriate jurisdiction to be invalid, that invalidity shall not affect the directive.
"Living Will Directive
My wishes regarding life-prolonging treatment and artificially provided nutrition and
hydration to be provided to me if I no longer have decisional capacity, have a
terminal condition, or become permanently unconscious have been indicated by
checking and initialing the appropriate lines below. By checking and initialing the
appropriate lines, I specifically:
.... Designate ........................ as my health care surrogate(s) to make health care
decisions for me in accordance with this directive when I no longer have decisional
capacity. If ............................. refuses or is not able to act for me, I designate
.............................. as my health care surrogate(s).
Any prior designation is revoked.
If I do not designate a surrogate, the following are my directions to my attending
physician. If I have designated a surrogate, my surrogate shall comply with my
wishes as indicated below:
.... Direct that treatment be withheld or withdrawn, and that I be permitted to die
naturally with only the administration of medication or the performance of any
medical treatment deemed necessary to alleviate pain.
.... DO NOT authorize that life-prolonging treatment be withheld or withdrawn.
.... Authorize the withholding or withdrawal of artificially provided food, water, or
other artificially provided nourishment or fluids.
.... DO NOT authorize the withholding or withdrawal of artificially provided food,
water, or other artificially provided nourishment or fluids.
.... Authorize my surrogate, designated above, to withhold or withdraw artificially
provided nourishment or fluids, or other treatment if the surrogate determines that
withholding or withdrawing is in my best interest; but I do not mandate that
withholding or withdrawing.
.... Authorize the giving of all or any part of my body upon death for any purpose
specified in KRS 311.1929.
.... DO NOT authorize the giving of all or any part of my body upon death.
In the absence of my ability to give directions regarding the use of life-prolonging
treatment and artificially provided nutrition and hydration, it is my intention that this
directive shall be honored by my attending physician, my family, and any surrogate
designated pursuant to this directive as the final expression of my legal right to
refuse medical or surgical treatment and I accept the consequences of the refusal.
If I have been diagnosed as pregnant and that diagnosis is known to my attending
physician, this directive shall have no force or effect during the course of my
pregnancy.
I understand the full import of this directive and I am emotionally and mentally
competent to make this directive.
Signed this .... day of .........., 19...
Signature and address of the grantor.
In our joint presence, the grantor, who is of sound mind and eighteen (18) years of
age, or older, voluntarily dated and signed this writing or directed it to be dated and
signed for the grantor.
Signature and address of witness.
Signature and address of witness.
OR
STATE OF KENTUCKY)
...........County)
Before me, the undersigned authority, came the grantor who is of sound mind and
eighteen (18) years of age, or older, and acknowledged that he voluntarily dated and
signed this writing or directed it to be signed and dated as above.
Done this .... day of ........, 19...
Signature of Notary Public or other officer.
Date commission expires:.............
Execution of this document restricts withholding and withdrawing of some medical
procedures. Consult Kentucky Revised Statutes or your attorney."
(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 the grantor and in the presence of each other, or acknowledged
before a notary public or other person authorized to administer oaths. None of
the following shall be a witness to or serve as a notary public or other person
authorized to administer oaths in regard to any advance directive made under
this section:
(a) A blood relative of the grantor;
(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
(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 surrogate, if any; to the attending physician; and to any health care
facility which is 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 the grantor within the fourth degree of consanguinity or affinity
or a member of the same religious or fraternal order.
Effective:June 25, 2013
History: Amended 2013 Ky. Acts ch. 127, sec. 2, effective June 25, 2013. -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 July 15, 1998. -- Created 1994 Ky. Acts ch. 235, sec. 3, effective July
15, 1994.
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