Guam § 91103 - Declaration Concerning Life-Sustaining Treatment; Execution

§ 91103. 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 deci-

sions regarding my medical treatment, I direct my attending

physician, pursuant to the Natural Death Act of Guam, to with-

hold 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

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 pro-

vider, an employee of a health care provider, the operator of a

community care facility, an employee of an operator of a commu-

nity 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.