Living Will
(Advance Medical Directive)
STATE OF LOUISIANA
PARISH OF _______________________________
I, ____________________________________________, being of sound mind, willfully and voluntarily make
known my desire that my dying shall not be artificially prolonged under the circumstances set forth below
and do hereby declare:
1. If all of the following conditions are present, I state that the procedures checked “NO” in Paragraph 2
below should be withheld or stopped and that I should be allowed to die naturally with only the giving of
medication or the doing of any medical procedure that is necessary to provide me with comfort care:
a. I have an incurable injury, disease or illness or I am in a continual deep comatose state with no
reasonable chance of getting well; and
b. I have been personally examined by two physicians (at least one of whom shall be my treating
physician) and both physicians certify in writing:
1. That my condition is terminal, irreversible and will likely cause my death in the near
future, whether or not life-sustaining procedures are used and
2. Application of the procedures would only artificially put off the dying process, or
3. That I am in a continual deep comatose state with no reasonable chance of ever
getting well.
2. I make the following directions concerning these procedures. Checking YES means I want the treatment.
Checking NO means I do not want the treatment.
YES
NO
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Cardiopulmonary Resuscitation - using drugs and electric shock to keep
my heart beating and helping me to breathe
Mechanical Breathing - ventilation; using a machine to help me breathe
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Major Surgery - such as removing my gall bladder or part of my intestines
Kidney Dialysis - using machines to clean my blood
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Chemotherapy - using drugs to fight cancer
Invasive Diagnostic Tests - such as using a tube to look into my stomach
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Artificial Nutrition and Hydration - giving me food and fluid through a
tube in my veins, nose or stomach
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Blood or Blood Products - such as giving me a transfusion
Antibiotics - using drugs to fight infection
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Simple Diagnostic Tests - such as blood tests or x-rays
Pain Medications - even if they make me sleepy or indirectly shorten my life
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