Submit a Revision

*your email :**
page name* : such as "Introduction", "Conclusion"..etc
<p> 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procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the provision of appropriate nutrition and hydration and the administration of essential medications and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. </p> <p> 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 </p> <p> ____________ 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. </p> <p> Signed _____________ Date _______ </p> <p> Place ______________ </p> <p> The declaring person has been personally known to me and I believe (him/her) to be of sound mind. </p> <p> 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. </p> <p> Witness (to the document) _________________ </p> <p> Date________________ </p> <p> Witness (second) _________________ </p> <p> Date________________ </p> <p> </p> <p> <strong>Corresponding author</strong> </p> Mohamad Said Maani Takrouri MB. ChB. FRCA (I) <br> Department of Anesthesia <br> King Fahad Medical City <br> Riyadh, Kingdom Saudi Arabia.
Confirmation code: Enter the code exactly as it appears. All letters are case insensitive, there is no zero.