(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 declarant may designate another individual of sound mind and 18 or more years of age to make decisions governing the withholding or withdrawal of life sustaining treatment. The declaration must be signed by the declarant, or another at the declarant's direction, and witnessed by two individuals.
(b) A declaration directing a physician to withhold or withdraw life-sustaining treatment may, but need not, be in the following form:
If I should have, in the opinion of my attending physician, an incurable and irreversible condition that, without the administration of life-sustaining treatment, will, in the opinion of my attending physician, 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, pursuant to the Uniform Rights of the Terminally Ill Act of this Territory, to withhold or withdraw treatment that, in the opinion of my attending physician, only prolongs the process of dying and is not necessary to my comfort or to alleviate pain.
Signed this____ day of ____, 19 ____
Signature ____
Address ____
The declarant voluntarily signed this writing in my presence.
Witness ____
Address ____
Witness ____
Address ____
(c) A declaration that designates another individual to make decisions to withhold or withdraw life-sustaining treatment may, but need not, be in the following form:
If I should have, in the opinion of my attending physician, an incurable and irreversible condition that, without the administration of life-sustaining treatment, will, in the opinion of the attending physician, cause my death within a relatively short time, and I am no longer able to make decisions regarding my medical treatment, I appoint [name of designee] or, if he or she is not reasonably available or is unwilling to serve, [name of alternate designee] to make decisions on my behalf regarding withholding or withdrawal of treatment that only prolongs the process of dying and is not necessary to my comfort or to alleviate pain pursuant to the Uniform Rights of the Terminally Ill Act of this Territory.
[If the individual(s) I have so appointed is (are) not reasonably available or is (are) unwilling to serve, I direct my attending physician, pursuant to the Uniform Rights of the Terminally Ill Act of this Territory, to withhold or withdraw treatment that in his or her opinion, only prolongs the process of dying and is not necessary to my comfort or to alleviate pain.] The bracketed language should be stricken if not desired by a declarant.
Signed this____ day of ____, 19 ____.
Signature ____
Address ____
The declarant voluntarily signed this writing in my presence.
Witness ____
Address ____
Witness ____
Address ____
Name and address of designee.
Name ____
Address ____
(d) The designation of an attorney in fact pursuant to the Uniform Durable Power of Attorney Act (Title 15, chapter 63, Virgin Islands Code), or the judicial appointment of a guardian, who is authorized to make decisions regarding the withholding or withdrawal of life-sustaining treatment, constitutes for the purposes of this chapter a declaration designating another individual to act for the declarant pursuant to subsection (a) of this section.
(e) 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 and the designee, if any.