Advance Health Care Directive Template Page 3
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6A. END OF LIFE INSTRUCTIONS
1. Choice To Prolong Life
_____I want my life to be prolonged as long as possible within the limits of generally
accepted health care standards.
OR
2. Choice Not To Prolong Life
I do not want my life to be prolonged if (please check all that apply)
____ (i) I have a terminal condition (an incurable condition from which there is no
reasonable medical expectation of recovery and which will cause my death, regardless
of the use of life-sustaining treatment). In this case, I give the specific directions
indicated:
I want used
I do not want used
Artificial nutrition through a conduit
_______
_______
Hydration through a conduit
_______
_______
Cardiopulmonary resuscitation
_______
_______
Mechanical respiration
_______
_______
Other (explain) ________________
_______
_______
____________________________
_____ (ii) I become permanently unconscious (a medical condition that has existed at
least four (4) weeks and has been diagnosed in accordance with currently accepted
medical standards and with reasonable medical certainty as total and irreversible loss of
consciousness and capacity for interaction with the environment. The term includes,
without limitation, a persistent vegetative state or irreversible coma) and regarding the
following, I give the specific directions indicated:
I want used
I do not want used
Artificial nutrition through a conduit
_______
_______
Hydration through a conduit
_______
_______
Cardiopulmonary resuscitation
_______
_______
Mechanical respiration
_______
_______
Other (explain) ________________
_______
_______
____________________________
B. RELIEF FROM PAIN:
Whether I choose A.1 or A.2, or neither, I direct that in all cases I
be given all medically appropriate care necessary to make me comfortable and alleviate pain.
C. OTHER MEDICAL INSTRUCTION: If you wish to add to the instructions you have given
above, you may do so here.
_________________________________________________________________________________
_________________________________________________________________________________
(use additional sheets if necessary)
Advance Health Care Directive of ________________________________________________________
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