A. At any time, a parent or guardian may make a written declaration directing the withholding or withdrawal of life-sustaining procedures for his child in the event the child should have a terminal and irreversible condition.
B. The declaration shall be signed by the parent or guardian in the presence of two witnesses.
C. It shall be the responsibility of the parent or guardian to notify the child's attending physician that a declaration has been made.
D. Any attending physician who is so notified shall promptly make the declaration or copy of the declaration a part of the child's medical record.
E. Nothing in this Article shall be construed to require the making of a declaration for a terminally ill minor. The legislature intends that the provisions of this Chapter are permissive and voluntary. The legislature further intends that the making of a declaration pursuant to this Chapter merely illustrates a means of documenting the decision relative to withholding or withdrawal of medical treatment or life-sustaining procedures by a parent or guardian on behalf of his child.
F. The declaration may but need not be in the following illustrative form and may include other specific directions:
"DECLARATION
Declaration made this _____ day of ______________ (month, year)
I, _______________, being of sound mind, willfully and voluntarily make known my desire that the death of my dying child, __________________________________, shall not be artificially prolonged under the circumstances set forth below and do hereby declare:
Because my child has an incurable condition, injury, disease, or illness certified to be terminal and irreversible by two physicians who have personally examined my child, one of whom is his attending physician, and the physicians have determined that my child's death will occur whether or not life-sustaining procedures are utilized and that the application of life-sustaining procedures will serve only to prolong artificially the dying process, I direct that such procedures be withheld or withdrawn and that my child be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide him with comfort care.
I understand the full import of this declaration, and I am emotionally and mentally competent to make this declaration on behalf of my child.
Signed _________________________
City, Parish, and State of Residence ______________________
The declarant has been personally known to me and I believe him or her to be of sound mind.
___________________________
Witness
___________________________
Witness"
Acts 1991, No. 235, §15, eff. Jan. 1, 1992.