This Declaration on Life and Death, made
while I am of sound mind, is intended to convey my desire that my dying not
be artificially prolonged under the circumstances set forth below.
Because of my Catholic belief in the dignity of the human person and my
eternal destiny with God, I ask my family, physicians, lawyer, pastor, and
friends to fully inform me of my condition and prognosis, if I should become
irreversibly and terminally ill, so that I can prepare myself spiritually
for death.
I am executing this Declaration in order to make known my decisions
concerning medical treatment that might unnecessarily prolong the dying
process beyond the limits dictated by reason and good judgment.
I do therefore declare that if at any time I am mentally or physically
unable to make my own health care decisions and unlikely to regain such
capacity and:
[initial below the one(s) you want to apply]
(initial)
________ I have a terminal condition from which I will
inevitably die with or without treatment;
________ I have an end-stage condition (an irreversible
and progressive condition caused by an illness or injury which has reached
its final stages, and for which, to a reasonable degree of medical
certainty, further treatment would be medically ineffective);
________ I am in a persistent vegetative state (a permanent and
irreversible condition in which the patient is totally unaware and totally
unable to communicate);
and if my attending or treating physician and another consulting physician
have determined that I have one of the conditions I have initialed above and
there is no reasonable medical expectation of my recovery from such
condition, then I request and direct: 1) that my pain be alleviated;
2) that no excessively burdensome nor disproportionate means be used to
prolong my life; and 3) that nothing should be done with the intention of
causing my death.
I believe nutrition and hydration are generally beneficial, whether being
administered orally or with assistance. Therefore, they are not to be
withheld or withdrawn from me unless there is clear evidence, in the
judgment of my physicians and my surrogate (if I have designated a
surrogate), that they would cause me harm, be disproportionate, or be
excessively burdensome.
I understand the full import of this Declaration, and I am emotionally and
mentally competent to make this Declaration. It is my intention that
this Declaration be honored by my family and physician(s) as the final
expression of my legal right to refuse medical or surgical treatment and to
accept the consequences of such refusal.
Additional Instructions (Optional):
I ask my family, friends and the Catholic community to join me in prayer as
I prepare for death. Finally, I seek prayers after my death, that I
may enjoy eternal life.
Signed this ______ day of __________________ , 20 ___ .
________________________________
(Signature) ________________________________
(Address)
The declarant is personally known to me,
and I believe him/her to be of sound mind. (The witnesses cannot be the
health care surrogate; only one witness can be a spouse or blood relative of
the signer.)
________________________________
(Witness)
________________________________ (Witness)
________________________________
(Address) ________________________________
(Address)
________________________________
(Phone) ________________________________
(Phone)
Designation of Health Care
Surrogate
of
___________________________________________________
(Name)
Should I become comatose, incompetent or
otherwise mentally or physically incapable of communication, I designate the
following as my surrogate, to make health care decisions for me, including
decisions to apply for public benefits, and authorize my admission or
transfer to a health care facility.
_________________________________________ (Name)
_________________________________________ (Address)
_________________________________________
_________________________________________ (Phone)
If that person is unwilling or unable to act, then as my
alternate surrogate:
_________________________________________ (Name)
_________________________________________ (Address)
_________________________________________
_________________________________________ (Phone)
(Additional Directions)
Signed this ______ day of _________________ , 20 _____ .
_________________________________________ (Signature)
_________________________________________ (Address)
_________________________________________
The declarant is personally known to me and I believe him/her to be of sound
mind. (The witnesses cannot be the health care surrogate; only one
witness can be a spouse or relative of the signer.)
_______________________________ (Witness)
_______________________________ (Witness)
________________________________ (Address)
________________________________ (Address)
________________________________ (Phone)
________________________________ (Phone)
In April 1989, the Catholic Bishops of
Florida issued a statement on Life, Death and the Care of Dying
Patients. Portions of that statement appear below:
. . . Our Judeo-Christian heritage
holds that life is the gift of a loving God, and that each human being is
made in the image and likeness of God. As Christians we also
celebrate the fact that we have been redeemed by Jesus Christ and are
called to share eternal life. We see life as a sacred trust over
which we can claim stewardship, but not absolute dominion.
Therefore the Church condemns all direct
attacks on life at any of its stages, including murder, euthanasia and
willful suicide. . . .
These prohibitions against murder,
euthanasia, suicide and assisted suicide are based on the inherent dignity
and fundamental value of each human being, and thus cannot be rejected on
grounds of political pluralism or religious freedom.
Prolonged illness and the agony it
sometimes brings cry out for the compassion and support of the entire
community. The story of Jesus tells us that suffering need not be useless,
but can become meaningful and redemptive through our response as we care
for the sick and especially for those who are terminally ill. Illness and
intense suffering do not justify the deliberate taking of human life, but
rather call for a profound recognition of and respect for the dignity of
the patient. Such dignity is not lost through illness because it resides
in our relationship to God. Consequently the deliberate taking of life,
even with the intention of ending suffering, is not permissible, nor is it
a response worthy of a faithful steward. Medicine that is administered to
suppress pain is permissible, even though it may have the side effect of
hastening death, so long as the intention is to ease the pain.
Faithful stewardship over life requires
us to preserve and promote it, to take care of our own health and to seek
necessary medical care from others. This does not require that every
possible remedy be used in every circumstance . .
In 1980, the Vatican Declaration on Euthanasia stated:
In the past, moralists replied that one
is never obliged to use "extraordinary" means. This reply,
which as a principle still holds good, is perhaps less clear today, by
reason of the imprecision of the term and the rapid progress made in the
treatment of sickness. Thus some people prefer to speak of
"proportionate" and "disproportionate" means. In
any case, it will be possible to make a correct judgment as to the means
by studying the type of treatment to be used, its degree of complexity or
risk, its cost and the possibilities of using it, and comparing these
elements with the result that can be expected, taking into account the
state of the sick person and his or her physical and moral resources.
The application of this principle becomes
difficult in many cases and should be made by the patient in consultation
with his or her family, physician, and priest or minister, whenever that is
possible . . .
A treatment is judged excessively
burdensome if it is too painful, too damaging to the patient's bodily self
and functioning, too psychologically repugnant to the patient, too
suppressive of the patient's mental life, or prohibitive in cost. Moral
certainty of excessive burdensomeness is required to justify withdrawal of
artificial hydration and nutrition.
There are certain particular cautions that
should be taken in executing a living will. First, the document should
clearly distinguish between a terminal condition in which death is imminent,
and other conditions in which one could live a long time with easily
provided medical care. Second, one should never ask for or demand
euthanasia, mercy killing or the withholding of "ordinary means"
of sustaining life. This is not only wrong for the signer of the document,
but it also does a serious injustice to physicians, family and medical
personnel to whom such immoral demands are made. Third, if there is
any possibility that the signer may become pregnant, then certainly every
measure should be called for to preserve the life of the unborn child.
Whenever a person executes such a
document, he or she has to confront the realities of life and of death. It
is a time when the family, especially a spouse, should be consulted and
decisions are best made together. A person's physician and sometimes an
attorney should be consulted. One need not shy away from executing a living
will . . .
Reprinted with permission Florida Catholic Conference
The Archdiocese of Baltimore has a 35-page
2007 Pastoral Letter entitled, Comfort and Consolation: Care of the Sick
and Dying including a 4-page health directive which can be purchased for
$4.75 at www.mdcathcon.org
