Declaration made this ________day of
______, 20__, _____________, a Muslim of sound mind, willfully and voluntarily
make known my desires that my dying shall not be artificially prolonged under
the circumstances set forth below and I declare: If at any time I have an
incurable injury, disease or illness certified in writing to be a terminal
condition by my attending physician(s), and my attending physician has
determined that the use of life-prolonging procedures would serve only to
artificially prolong the dying process, I direct that such procedures be
withheld or withdrawn, and that I be permitted to die naturally with only the
provision of appropriate nutrition and hydration and the administration of
essential medications and the performances of any medical procedures necessary
(as determined by my physician) to provide me with comfort or to alleviate
pain.
In the absence of my ability to give
direction regarding the use of life-prolonging procedures, it is my intention
that this declaration be honored by my family and physician as the final
expression of my legal right to refuse medical or surgical treatment and I
accept the consequences of the refusal
____________ is my case manager to
enforce my living will, if I am not physically able to give direction. I do not
permit autopsy of my body unless my death occurred in a suspicious manner and
it is important to know the cause of death or if it is required by the court of
law. It is my desire that Muslims attending my dying process ensure that
Islamic Shari‘ah is practiced during preparation of my body for burial and that
my body be treated with grace and privacy and buried with Islamic guidelines
under the directions of my Muslim family, Imam or other qualified Muslims as
soon as it is feasible.
Signed _____________ Date _______
Place ______________
The declaring person has been
personally known to me and I believe (him/her) to be of sound mind.
I did not sign the declaring
person's signature above for or at the direction of the declaring person. I am
not a parent, spouse, or child of the declaring person. I am not entitled to
any part of the declaring person's estate or directly financially responsible
for his/her medical care. I am competent and at least eighteen (18) years of
age.
Witness (to the document)
_________________
Date________________
Witness (second) _________________
Date________________
Corresponding
author
Mohamad
Said Maani Takrouri MB. ChB. FRCA (I)
Department of Anesthesia
King Fahad Medical City
Riyadh, Kingdom Saudi Arabia.
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