KRS 311.625: Form of living will directive.

(1) A living will directive made pursuant to KRS 311.623 shall be substantially in the

following form, and may include other specific directions which are in accordance

with accepted medical practice and not specifically prohibited by any other statute.

If any other specific directions are held by a court of appropriate jurisdiction to be

invalid, that invalidity shall not affect the directive.

"Living Will Directive

My wishes regarding life -prolonging treatment and artificially provided nutrition and

hydration to be provided to me if I no longer have decisional capacity, have a terminal

condition, or become permanently unconscious have been indicated by checking and

initialing the appropriate lines below. By checking and initialing the appropriate lines, I

specifically:

.... Designate ........................ as my health care surrogate(s) to make health care decisions

for me in accordance with this directive when I no longer have decisional capacity. If

............................. refuses or is not able to ac t for me, I designate .............................. as

my health care surrogate(s).

Any prior designation is revoked.

If I do not designate a surrogate, the following are my directions to my attending

physician. If I have designated a surrogate, my surrog ate shall comply with my wishes as

indicated below:

.... Direct that treatment be withheld or withdrawn, and that I be permitted to die naturally

with only the administration of medication or the performance of any medical treatment

deemed necessary to alleviate pain.

.... DO NOT authorize that life-prolonging treatment be withheld or withdrawn.

.... Authorize the withholding or withdrawal of artificially provided food, water, or other

artificially provided nourishment or fluids.

.... DO NOT authorize the w ithholding or withdrawal of artificially provided food, water,

or other artificially provided nourishment or fluids.

.... Authorize my surrogate, designated above, to withhold or withdraw artificially

provided nourishment or fluids, or other treatment if t he surrogate determines that

withholding or withdrawing is in my best interest; but I do not mandate that withholding

or withdrawing.

.... Authorize the giving of all or any part of my body upon death for any purpose

specified in KRS 311.1929.

.... DO NOT authorize the giving of all or any part of my body upon death.

In the absence of my ability to give directions regarding the use of life -prolonging

treatment and artificially provided nutrition and hydration, it is my intention that this

directive shall be honored by my attending physician, my family, and any surrogate

designated pursuant to this directive as the final expression of my legal right to refuse

medical or surgical treatment and I accept the consequences of the refusal.

If I have bee n diagnosed as pregnant and that diagnosis is known to my attending

physician, this directive shall have no force or effect during the course of my pregnancy.

I understand the full import of this directive and I am emotionally and mentally

competent to make this directive.

Signed this .... day of .........., 19...

Signature and address of the grantor.

In our joint presence, the grantor, who is of sound mind and eighteen (18) years of age, or

older, voluntarily dated and signed this writing or directed it to be dated and signed for

the grantor.

Signature and address of witness.

Signature and address of witness.

OR

STATE OF KENTUCKY)

...........County)

Before me, the undersigned authority, came the grantor who is of sound mind and

eighteen (18) years of age, or older, and acknowledged that he voluntarily dated and

signed this writing or directed it to be signed and dated as above.

Done this .... day of ........, 19...

Signature of Notary Public or other officer.

Date commission expires:.............

Execution of this document restricts withholding and withdrawing of some medical

procedures. Consult Kentucky Revised Statutes or your attorney."

(2) An advance directive shall be in writing, dated, and signed by the grantor, or at the

grantor's direction, and either witnessed by two (2) or more adults in the presence of

the grantor and in the presence of each other, or acknowledged before a notary

public or other person authorized to administer oaths. None of the following shall

be a witness to or serve as a notary public or other person authorized to administer

oaths in regard to any advance directive made under this section:

(a) A blood relative of the grantor;

(b) A beneficiary of the grantor under descent and distribution statutes of the

Commonwealth;

(c) An employee of a health care facility in which the grantor is a patient, unless

the employee serves as a notary public;

(d) An attending physician of the grantor; or

(e) Any person directly financially responsible for the grantor's health care.

(3) A person designated as a surrogate pursuant to an advance directive may resign at

any time by giving written notice to the grantor; to the immediate successor

surrogate, if any; to the attending physician; and to any health care facility which is

then waiting for the surrogate to make a health care decision.

(4) An employee, owner, director, or officer of a health care facility where the grantor

is a resident or patient shall not be designated or act as surrogate unless related to

the grantor within the fourt h degree of consanguinity or affinity or a member of the

same religious or fraternal order.