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Kansas Living Will Declaration Form

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The Kansas Living Will Declaration will generally state that if you are terminally ill, then the Declarant/Principal may choose to put into writing, that death-delaying procedures are not be used to prolong the life of the Declarant/Principal. The document provides plenty of specifics to be certain that the Declarant/Principal received exactly the medical treatment that they prefer, leaving no one else to have to make difficult decisions with regard to their loved one. If you’re uncertain how this document will work for you, you may wish to consult with an attorney, prior to implementation.

LawsKSA 65-28,101

Medical Power of Attorney – For the option of having a person who can make decisions on the behalf, and best interest, for health care reasons if they cannot do so for themselves.

How to Write

Step 1 – Declaration of Declarant/Principal – Enter the following:

  • Date the declaration at the top of the document in dd/mm/yyyy format
  • Enter the full legal name of the Declarant/Principal
  • Date of Birth
  • Declarant’s City of Residence
  • Declarant’s County of Residence
  • Declarant’s State of Residence
  • If the Declarant is interested in providing additional instructions they may do so by providing them on the back of the document or they may add a sheet with additional instructions and attach it to the document
  • Check the appropriate box indicating whether or not you would like to provide additions
  • Declarant/Principal shall then enter their signature

Step 2 – This document must be acknowledged by a notary public or two witnesses –

  • If witnesses will be signing the document they may not related to the principal by blood, marriage, or adoption. They may not be entitled to any portion of the principal’s estate, and in no way financially responsible for any aspect of the principal’s health care. If witnesses will be signing the document they must review the information on the document and then enter the following:

Witness 1 –

  • Witness’ Signature
  • Witness’ Full address

Witness 2 – 

  • Witness’ Signature
  • Witness’ Full address
  • OR

Notary Public – If the decision has been made for the notary to witness the document, once the notary has witnessed the Declarant’s Signature, notary will then complete the notary section of the document and affix their notary seal in acknowledgment

Step 3 – Optional Additional Instructions – If the Declarant/Principal would like to provide additional medical information with regard to their wishes, they may begin with reading the information at the top of page 2. If the Declarant/Principal would like to proceed with other options circle Yes or No to the following statements to each answer below:

When any of the conditions described in the preceding paragraph exist, I request that I be provided all of the following measures or interventions EXCEPT those that I have marked “No.”

  • SURGERY
  • DIALYSIS
  • HEART-LUNG RESUSCITATION (CPR)
  • ANTIBIOTICS
  • MECHANICAL VENTILATOR
  • TUBE FEEDING (respirator requiring intubation) (food and water delivered through a tube in the veins, nose, or stomach)
  • OTHER
  •  If my physician believes that any life-saving or life-prolonging measure or intervention may lead to a significant recovery (even those marked “No” above), I direct my physician to try the treatment for a reasonable period of time. If it does not significantly improve my condition, I direct the treatment be withdrawn, even if so doing shortens my life. Yes No I direct that in all circumstances, I be given healthcare treatment to relieve pain or provide comfort, even if such treatment might shorten my life, suppress my appetite or my breathing, or be habit-forming

Step 4 – Read the statement and enter any additional information:

  • I consider a “meaningful quality of life” to include the following, which shall be taken into consideration by any caregivers and/or surrogate decision makers in determining my course of medical treatment

Step 5 – Read the following and make any additions in the lines provided:

  • I make other instructions as follows:

Step 6 – Signatures – This area of the document must also be acknowledged by a notary public or two witnesses –

  • If witnesses will be signing the document they may not related to the principal by blood, marriage, or adoption. They may not be entitled to any portion of the principal’s estate, and in no way financially responsible for any aspect of the principal’s health care. If witnesses will be signing the document they must review the information on the document and then enter the following:

Witness 1 –

  • Witness’ Signature
  • Witness’ Full address

Witness 2 – 

  • Witness’ Signature
  • Witness’ Full address
  • OR
  • Notary Public – If the decision has been made for the notary to witness the document, once the notary has witnessed the Declarant’s Signature, notary will then complete the notary section of the document and affix their notary seal in acknowledgment

 

 

 

 


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