ADVANCE DIRECTIVE TO PHYSICIANS
Directive made this _____ day of _________________, 2005. I, Bruce Iverson Berryhill,
being of sound mind, willfully and voluntarily make known my desire that my life shall not be
artificially prolonged under the circumstances set forth below and do hereby declare:
If at any time two physicians, one of whom is the attending physician, confirm that I am in
one of the medical conditions described below:
- Close to Death. If I should have an incurable injury, disease or illness
certified to be a terminal condition and the application of
life-sustaining procedures would serve only to artificially prolong the moment of my death and
my physician determines that my death is imminent whether or not life-sustaining
procedures are utilized:
- Permanently Unconscious. If I am unconscious for more than two weeks
or it is very unlikely that I will ever become conscious again:
- Advanced Progressive Illness. If
I have a progressive illness that will be fatal and is in an advanced
stage, and I am consistently and permanently unable to communicate by
any means, swallow food and water safely, care for myself and recognize
my family and other people, and it is very unlikely that my condition
will substantially improve:
- Extraordinary Suffering. If life support would not help my medical
condition and would make me suffer permanent and severe pain:
I direct that life-sustaining procedures, including tube feeding, be withheld
or withdrawn, and that I be permitted to die naturally.
In the absence of my ability to give directions regarding the use of
such life-sustaining procedures, it is my intention that this declaration
shall be honored by my family and physician(s) as the final expression of
my legal right to refuse medical or surgical treatment and accept the
consequences from such refusal.
I do not want to be in pain. I want my physician to administer adequate medicine
to relieve my pain, even if it hastens my death or causes me to be drowsy or to
sleep more than usual.
I do not want to be an organ donor.
I understand the full import of this declaration and I am emotionally and
mentally competent to make this declaration.
I do not have a health care power of attorney.
Signed on this ______ day of _______________, 2005, in the City of
Sisters, County of Deschutes, State of Oregon.
______________________________________
Bruce Iverson Berryhill
DECLARATION OF WITNESSES
I hereby witness this declaration and attest that:
- I personally know the Declarant and believe the Declarant
to be of sound mind and not under duress, fraud or undue influence.
- To the best of my knowledge, at the time of the execution
of this declaration, I:
- Am not related to the Declarant by blood or marriage,
- Do not have any claim on the estate of the Declarant,
- Am not entitled to any portion of the Declarant's estate by
any will or by operation of law,
- Am not appointed as the Declarant's health care representative or alternative
health care representative, and
- Am not a physician attending the Declarant, a person employed
by a physician attending the Declarant or a person employed by a health
facility in which the Declarant is a patient.
- I understand that if I have not witnessed this directive in good faith I
may be responsible for any damages that arise out of giving this directive
its intended effect.
By my signature on this directive, I attest the Declarant signed this document in my
presence and in the presence of other said witness.
I declare under penalty of perjury under the laws of the State of
Oregon that the foregoing is true and correct.
Executed on this _________ day of the month of ________________, 2005, in the
County of Deschutes, State of Oregon.
First Witness:
______________________________, residing at ______________________________
(Signature Above)
_____________________________________________________________________
______________________________
(Print Name Above)
Second Witness:
______________________________, residing at _____________________________
(Signature Above)
____________________________________________________________________
_____________________________
(Print Name Above)