LIVING WILL OF _______________________________ I, _______________________________, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, and do hereby declare: If at any time I should have a terminal condition and my attending physician has determined there is no reasonable medical expectation of recovery and which, as a medical probability, will result in my death, regardless of the use or discontinuance of medical treatment implemented for the purpose of sustaining life, or the life process, I direct that medical care be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medications or the performance of any medical procedure deemed necessary to provide me with comfortable care or to alleviate pain. ARTIFICIALLY PROVIDED NOURISHMENT AND FLUIDS: By checking the appropriate line below: I specifically: ______ authorize the withholding or withdrawal of artificially provided food, water, or other nourishment or fluids. ______ DO NOT authorize the withholding or withdrawal of artificially provided food, water, or other nourishment or fluids. ORGAN DONOR CERTIFICATION: Notwithstanding my previous declaration relative to the withholding or withdrawal of life prolonging procedures, if as indicated below I have expressed my desire to donate my organs and/or tissues for transplantation, or any of them as specifically designated herein, I do direct my attending physician, if I have been determined dead according to Tennessee Code Annotated, Section 68 3 501(b), to maintain me on artificial support systems only for the period of time required to maintain the viability of and to remove such organs and/or tissues. By checking the appropriate line below I specifically: _____ desire to donate my organs and/or tissues for transplantation. _____ desire to donate my _________________________________________ (insert specific organs or tissues for transplantation.) _____ DO NOT desire to donate my organs or tissues for transplantation. In the absence of my ability to give directions regarding my medical care, it is my intention that this declaration shall be honored by my family and physician as the final expression of my legal right to refuse medical care and accept the consequences of such refusal. The Living Will shall be given effect and interpreted in accordance with the provisions of Tennessee Code Annotated Section 32-11-101, et seq. The definitions of terms used herein shall be as set forth in the Tennessee Right to Natural Death Act, Tennessee Code Annotated, Section 32 11 103. I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration. In acknowledgment whereof, I do hereinafter affix my signature on this the ____ day of _______________, 20_______. __________________________________ DECLARANT STATE OF TENNESSEE COUNTY OF SHELBY BEFORE ME, the undersigned Notary Public in and for the State and County aforesaid, duly commissioned and qualified, personally appeared _______________________________, the within named bargainor, with whom I am personally acquainted (or proved to me on the basis of satisfactory evidence), and who acknowledged upon oath or affirmation that he/she executed the within instrument of his/her own free act and deed for the purposes therein contained. WITNESS my hand, at office, in Memphis, Shelby County, Tennessee on this _______ day of ____________, 20_______. ______________________________________ NOTARY PUBLIC My Commission Expires: ________________________