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are not to be withheld or withdrawn from me unless there is clear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)
Florida
Catholic Conference
Catholic Declaration on Life
and Death - Advance Directive
(Health Surrogate Designation/Living Will)
Florida Catholic
Conference 201 W Park Ave
Tallahassee, FL 32301-7760 Telephone: (850) 222-3803 ·
Fax: (850) 681-9548 · Website: http://www.flacathconf.org
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 . . .
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
