A declaration directing a physician or advanced practice registered nurse to withhold or withdraw life-sustaining treatment may, but need not, be in the following form:
DECLARATION
If I should have an incurable and irreversible condition that, without the administration of life-sustaining treatment, will, in the opinion of my attending physician or attending advanced practice registered nurse, cause my death within a relatively short time, and I am no longer able to make decisions regarding my medical treatment, I direct my attending physician or attending advanced practice registered nurse, pursuant to NRS 449A.400 to 449A.481, inclusive, to withhold or withdraw treatment that only prolongs the process of dying and is not necessary for my comfort or to alleviate pain.
If you wish to include this statement in this declaration, you must INITIAL the statement in the box provided:
Withholding or withdrawal of artificial nutrition and hydration may result in death by starvation or dehydration. Initial this box if you want to receive or continue receiving artificial nutrition and hydration by way of the gastrointestinal tract after all other treatment is withheld pursuant to this declaration.
[............................................ ]
Signed this ........................ day of ................, ......
Signature .........................................................
Address ...........................................................
The declarant voluntarily signed this writing in my presence.
Witness ...........................................................
Address ...........................................................
Witness ...........................................................
Address ...........................................................
(Added to NRS by 1977, 760; A 1991, 633; 1993, 2790; 2017, 1757) — (Substituted in revision for NRS 449.610)
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