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    WMREF Kansas Living Will Form

    Uploaded by

    nazlifathima2023
    This document is a living will declaration form according to the Kansas Natural Death Act. It allows the declarant to specify their wishes regarding life-sustaining medical procedures if they become terminally ill and unable to communicate their wishes. The declarant declares that if they have an incurable injury or illness certified as terminal by two examining physicians, life-sustaining procedures may be withdrawn to allow them to die naturally with comfort care. The declarant understands this decision and wants their wishes honored by family and doctors as their final expression to refuse treatment. The declaration must be witnessed or notarized to be valid.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    WMREF Kansas Living Will Form

    Uploaded by

    nazlifathima2023
    16 views1 page
    This document is a living will declaration form according to the Kansas Natural Death Act. It allows the declarant to specify their wishes regarding life-sustaining medical procedures if they become terminally ill and unable to communicate their wishes. The declarant declares that if they have an incurable injury or illness certified as terminal by two examining physicians, life-sustaining procedures may be withdrawn to allow them to die naturally with comfort care. The declarant understands this decision and wants their wishes honored by family and doctors as their final expression to refuse treatment. The declaration must be witnessed or notarized to be valid.

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    WMREF-Kansas-Living-Will-Form

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    This document is a living will declaration form according to the Kansas Natural Death Act. It allows the declarant to specify their wishes regarding life-sustaining medical procedures if they become terminally ill and unable to communicate their wishes. The declarant declares that if they have an incurable injury or illness certified as terminal by two examining physicians, life-sustaining procedures may be withdrawn to allow them to die naturally with comfort care. The declarant understands this decision and wants their wishes honored by family and doctors as their final expression to refuse treatment. The declaration must be witnessed or notarized to be valid.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    16 views1 page

    WMREF Kansas Living Will Form

    Uploaded by

    nazlifathima2023
    This document is a living will declaration form according to the Kansas Natural Death Act. It allows the declarant to specify their wishes regarding life-sustaining medical procedures if they become terminally ill and unable to communicate their wishes. The declarant declares that if they have an incurable injury or illness certified as terminal by two examining physicians, life-sustaining procedures may be withdrawn to allow them to die naturally with comfort care. The declarant understands this decision and wants their wishes honored by family and doctors as their final expression to refuse treatment. The declaration must be witnessed or notarized to be valid.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    LIVING WILL DECLARATION

    Kansas Natural Death Act

    I, _________________________________, being withdrawn and that I be permitted to die naturally


    of sound mind, willfully and voluntarily making with only the administration of medication or the
    performance of any
    known my desire that my dying shall not be medical procedure deemed necessary to provide me
    artificially prolonged under the circumstances with comfort care.
    set forth below, do hereby declare: In the absence of my ability to give directions
    regarding the use of such life-sustaining procedures,
    If at any time I should have an incurable injury, it is my intention that this declaration shall be
    disease, or illness certified to be a terminal condition honored by my family and physician(s) as the final
    by two physicians who have personally examined me, expression of my legal right to refuse medical or
    one of whom shall be my attending physician, and the surgical treatment and accept the consequences from
    physicians have determined that my death will occur such refusal.
    whether or not life-sustaining procedures are utilized I understand the full import of this declaration
    and where the application of life-sustaining procedures and I am emotionally and mentally competent to
    would serve only to artificially prolong the dying make this decision. any Living Will declaration I
    process, I direct that such procedures be withheld or have previously made is hereby revoked.

    Declarations made this (day) of (month, year)


    Signature:
    X ________________________________________ Date of Birth _______________________
    Address: __________________________________________________________________
    street city state zip

    This document must be witnessed by two individuals or acknowledged by a notary public.


    Notary Public: Notary Seal:
    STaTe Of COuNTY Of

    This instrument was acknowledged before me this day of (month, year)

    Signature of Notary

    or
    Witnesses:
    The declarant has been personally known to me and I believe the declarant to be of sound mind. I did not sign the declarant's
    signature above for or at the direction of the declarant. I am not related to the declarant by blood or marriage, entitled to any
    portion of the estate of the declarant according to the laws of intestate succession or under any will of declarant or codicil
    thereto, or directly responsible for declarant’s medical care.
    Name: _______________________________________________ Name: __________________________________________

    address: _____________________________________________ address: ________________________________________

    City, State, Zip: ________________________________________ City, State, Zip:___________________________________

    This document is based on Kansas Statute 65-28,101 et seq. as


    amended Additional forms and information are available through

    Wichita Medical Research & Education Foundation


    3306 E. Central, Wichita, KS 67208
    316-686-7172 Reprinted 9/2011
    www.wichitamedicalresearch.org

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