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Utah Advance Health Care Directive Page 3

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Part II: My Health Care Wishes

(Living Will)

I want my health care providers to follow the instructions I give them when I am being treated, even if my instructions conflict

with these or other advance directives. My health care providers should always provide health care to keep me as comfortable

and functional as possible.

Choose only one of the following options, numbered Option 1 through Option 4, by placing your initials before the numbered

statement. Do not initial more than one option. If you do not wish to document end-of-life wishes, initial Option 4. You may

choose to draw a line through the options that you are not choosing.

Option 1

I choose to let my agent decide. I have chosen my agent carefully. I have talked with my agent about my

health care wishes. I trust my agent to make the health care decisions for me that I would make under the

circumstances.

Initial

Additional comments:

Option 2

I choose to prolong life. Regardless of my condition or prognosis, I want my health care team to try to

prolong my life as long as possible within the limits of generally accepted health care standards.

Initial

Additional comments:

Option 3

I choose not to receive care for the purpose of prolonging life, including food and fluids by tube, antibiotics,

CPR, or dialysis being used to prolong my life. I always want comfort care and routine medical care that will

Initial

keep me as comfortable and functional as possible, even if that care may prolong my life.

If you choose this option, you must also choose either (a) or (b), below

(a) I put no limit on the ability of my health care provider or agent to withhold or withdraw life-

sustaining care.

Initial

(b) My health care provider should withhold or withdraw life-sustaining care if at least one of the

initialed conditions is met:

Initial

I have a progressive illness that will cause death

If you

selected

I am close to death and am unlikely to recover

(a), above,

I cannot communicate and it is unlikely that my condition will improve

do not

choose any

I do not recognize my friends or family and it is unlikely that my condition will improve

options

under (b).

I am in a persistent vegetative state

Additional comments:

Option 4

I do not wish to express preferences about health care wishes in this directive.

Initial

Additional comments

Name: ______________________________________________

Page 3 of 4

Utah Advance Health Care Directive Page 3

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