Declaration Concerning Life-Sustaining Treatment; Execution

Requirements.

(a)An individual of sound mind and 18 or more years of age may execute at any time a declaration governing the withholding or withdrawal of life-sustaining treatment. The declaration shall be a separate document and not a part of another document nor contained on a piece of paper containing some other document, shall be signed by the declarant, or another at the declarant's direction and in the declarant's presence, and witnessed by two individuals neither of whom may be a person who is entitled to any portion of the estate of the qualified patient upon his or her death under any will or codicil thereto of the qualified patient existing at the time of execution of the declaration or by operation of law. In addition, a health care provider, an employee of a health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a residential care facility for the elderly, or an employee of an operator of a residential care facility for the elderly may not be a witness.

(b)A declaration shall substantially contain the following provisions: DECLARATION If I should have an incurable and irreversible condition that has been diagnosed by two physicians and that will result in my death within a relatively short time without the administration of life-sustaining treatment or has produced an irreversible coma or persistent vegetative state, and I am no longer able to make decisions regarding my medical treatment, I direct my attending physician, pursuant to the Natural Death Act of Guam, to withhold or withdraw life-sustaining treatment that only prolongs the process of dying or the irreversible coma or persistent vegetative state and is not necessary for my comfort, nutrition, hydration or to alleviate pain. COL092507 CH. 91 NATURAL DEATH ACT If I have been diagnosed as pregnant, and that diagnosis is known to my physician, this declaration shall have no force or effect during my pregnancy. Signed ______ this day of ________, _____ Signature________________________________ Address_________________________________ The declarant voluntarily signed this writing in my presence. I am not entitled to any portion of the estate of the declarant upon his or her death under any will or codicil thereto of the declarant now existing or by operation of law. I am not a health care provider, an employee of a health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a residential care facility for the elderly, or an employee of an operator of a residential care facility for the elderly. Witness___________Witness_____________ Address____________ Address___________

(c)A physician or other health care provider who is furnished a copy of the declaration shall make it a part of the declarant's medical record and, if unwilling to comply with the declaration, promptly so advise the declarant.

(d)A declaration may be made by parents or other adults who are legally responsible for a minor patient who is neither married nor emancipated.