Advance Directives
ADVANCE DIRECTIVE
LIVING WILL
(Optional Form)
If I am not able to make an informed decision regarding my health care, I direct my health care providers to follow my instructions as set forth below. (Initial those statements you wish to be included in the document and cross through those statements which do not apply.)
- If my death from a terminal condition is imminent and even if life-sustaining procedures are used there is no reasonable expectation of my recovery:
_______I direct that my life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artificially.
_______I direct that my life not be extended by life-sustaining procedures, except that, if I am unable to take food by mouth, I wish to receive nutrition and hydration artificially.
_______I direct that, even in a terminal condition, I be given all available medical treatment in accordance with accepted health care standards.
- If I am in a persistent vegetative state, that is, if I am not conscious and am not aware of my environment nor able to interact with others, and there is no reasonable expectation of my recovery within a medically appropriate period:
_______I direct that my life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artificially.
_______I direct that my life not be extended by life-sustaining procedures, except that, if I am unable to take in food by mouth, I wish to receive nutrition and hydration artificially.
_______I direct that I be given all available medical treatment in accordance with accepted health care standards.
- If I am pregnant, my decision concerning life-sustaining procedures shall be modified as follows:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
By signing below, I indicate that I am emotionally and mentally competent to make this Living Will and that I understand its purpose and effect.
(Date)________________________
(Signature of Declarant)___________________________________________
The declarant signed or acknowledged signing this Living Will in my presence and, based upon my personal observation appears to be a competent individual.
(Witness Signature)
_________________________________
(Address)
_________________________________
_________________________________
_________________________________
|
 |
(Witness Signature)
_________________________________
(Address)
_________________________________
_________________________________
_________________________________
|
|
