DECLLIFEDEATHFLCATHCONF.pdf

CATHOLIC DECLARATION ON LIFE AND DEATH
ADVANCE DIRECTIVE

(HEALTH SURROGATE DESIGNATION/LIVING WILL) OF

_________________________________________________________
(Name)

Introduction
I am executing this Catholic Declaration on Life and Death while I am of sound mind. It is intended to
designate a surrogate and provide guidance in making medical decisions in the event I am
incapacitated or unable to express my own wishes.

Statement of Faith
I believe that I have been created for eternal life in union with God. The truth that my life is a
precious gift from God has profound implications for the question of stewardship over my life. I have
a duty to preserve my life and to use it for God’s glory, but the duty to preserve my life is not
absolute, for I may reject life-prolonging procedures that are insufficiently beneficial or excessively
burdensome. Suicide and euthanasia are never morally acceptable options.

1
If I should become

irreversibly and terminally ill, I request to be fully informed of my condition so that I can prepare
myself spiritually for death and witness to my belief in Christ’s redemption.

Designation of Health Care Surrogate
In the event that I become incapacitated, I designate as my surrogate for health care decisions (if no
surrogate is to be appointed, please write “none” in place of “name” below):

Name:_________________________________________________________________

Address:_______________________________________________________________

Phones (H, W, C):________________________________________________________

If my surrogate is unwilling or unable to perform his or her duties or cannot be contacted, I wish to
designate as my alternate surrogate (if no alternate surrogate is to be appointed, please write “none”
in place of “name” below):

Name:_________________________________________________________________

Address:_______________________________________________________________

Phones (H, W, C):________________________________________________________

This directive will permit my surrogate to make health care decisions, and to provide, withhold, or
withdraw consent on my behalf; to apply for public benefits to defray the cost of health care; to
receive my personal health care information; and to authorize my admission to or transfer from a
health care facility. My surrogate is further appointed as my “Personal Representative.”

2
This

directive is not being made as a condition of treatment or admission to a health care facility. This
document must be signed and witnessed on the other side to be valid.

1
Cf United States Conference of Catholic Bishops, Ethical & Religious Directives for Catholic Health Care Services (USCCB: Washington,

DC 2009), Part Five.

2
As defined by 45 CFR 164.502(g), for purposes of compliance with Federal HIPAA Laws and Regulations (the Health Insurance Portability

and Accountability Act of 1996).

Living Will
The following gives guidance for carrying out my wishes at the end of life. If at any time I am incapacitated and I
have a terminal condition or I have an end-stage condition, and if my attending or treating physician and another
consulting physician have determined that there is no reasonable medical probability of my recovery from such
condition(s), my health care surrogate (designated above, if any) will be authorized to make decisions for me in
accordance with my wishes expressed in this Declaration. If my surrogate cannot be contacted (or I have not
named a surrogate), then I request and direct that each of the following be considered in making a decision for
me.

That:

1. I be provided care and comfort, and that my pain be relieved.

2. No inappropriate, excessively burdensome nor disproportionate means be used to prolong my life. This
can include medical or surgical procedures.

3. There should be a presumption in favor of providing nutrition and hydration to me, including medically
assisted nutrition and hydration, unless:

 They cannot reasonably be expected to prolong my life; or

 The means used to deliver the nutrition and hydration are excessively burdensome and do not
offer sufficient benefit or would cause me significant physical discomfort; or

 I am imminently dying from an irreversible condition.

4. Nothing be done with the intention of causing my death.

5. Spiritual care be provided, including sacraments whenever possible.

Additional Instructions

_______________________________________________________________________________________

_______________________________________________________________________________________

Signatures Required
It is my intention that my surrogate, family and physicians honor this declaration as the expression of my
treatment wishes. I understand the full import of this declaration, and I am emotionally and mentally competent
to make this declaration.

__________________________________________ _______________________________________

DECLARANT Date
Last 4 Social Security Number: ____________

__________________________________________ _______________________________________

Witness Signature Witness Signature

__________________________________________ _______________________________________

Printed/Typed Name Printed/Typed Name

The Health Care Surrogate cannot serve as a witness; at least one witness must not be a spouse or blood
relative of the person signing.

December 7, 2015

Copies of this form are available from the Florida Catholic Conference, 201 West Park Avenue, Tallahassee, FL 32301-7760
www.flaccb.org

http://www.flaccb.org/