DECLARATION
If I should have an incurable or irreversible condition that, without the administration of life-sustaining treatment, will, in the opinion of my attending physician or attending advanced practice registered nurse, cause my death within a relatively short time and I am no longer able to make decisions regarding my medical treatment, I direct my attending physician or attending advanced practice registered nurse, pursuant to the Montana Rights of the Terminally Ill Act, to withhold or withdraw treatment that only prolongs the process of dying and is not necessary to my comfort or to alleviate pain.
Signed this ____ day of _________, ____.
Signature _____________
City, County, and State of Residence ____________________
The declarant voluntarily signed this document in my presence.
Witness__________________________________
Address__________________________________
Witness__________________________________
Address__________________________________
DECLARATION
If I should have an incurable and irreversible condition that, without the administration of life-sustaining treatment, will, in the opinion of my attending physician or attending advanced practice registered nurse, cause my death within a relatively short time and I am no longer able to make decisions regarding my medical treatment, I appoint __________ or, if that person is not reasonably available or is unwilling to serve, __________, to make decisions on my behalf regarding withholding or withdrawal of treatment that only prolongs the process of dying and is not necessary for my comfort or to alleviate pain, pursuant to the Montana Rights of the Terminally Ill Act.
If the individual I have appointed is not reasonably available or is unwilling to serve, I direct my attending physician or attending advanced practice registered nurse, pursuant to the Montana Rights of the Terminally Ill Act, to withhold or withdraw treatment that only prolongs the process of dying and is not necessary for my comfort or to alleviate pain.
Signed this ____ day of _________, ____.
Signature____________________________
City, County, and State of Residence______________________
The declarant voluntarily signed this document in my presence.
Witness____________________________
Address________________________
Witness________________________
Address________________________
Name and address of designee.
Name__________________________
Address_______________________
§ 50-9-103, MCA