Durable Health Care Power Of Attorney Page 4
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4LIVING WILL
The following health treatment instructions exercise my right to make my own health care decisions
and are intended as clear and convincing evidence of my wishes when I lack the capacity to understand,
make or communicate my treatment decisions.
I IF I HAVE AN END-STAGE MEDICAL CONDITION (one which will result in my
death, despite the introduction or continuation of medical treatment) OR I AM
PERMANENTLY UNCONSCIOUS SUCH AS BEING IN AN IRREVERSIBLE COMA
OR AN IRREVERSIBLE VEGETATIVE STATE, AND THERE IS NO REALISTIC
HOPE OF SIGNIFICANT RECOVERY:
Cross out and initial treatment instructions with which you do not agree.
______ I direct that I be given health care treatment for pain relief or comfort even if it might
shorten my life, suppress my appetite or my breathing, or be habit-forming.
______ I direct that all life-prolonging procedures be withheld or withdrawn.
I IN ADDITION, IF I AM IN THE CONDITION DESCRIBED ABOVE:
I I
I I
I I
I I
I
DO
DO NOT
want cardiac resuscitation.
I
DO
DO NOT
want kidney dialysis.
I I
I I
I I
I I
I
DO
DO NOT
want blood or blood products.
I
DO
DO NOT
want antibiotics.
I I
I I
I I
I I
I
DO
DO NOT
want any form of surgery
I
DO
DO NOT
want tube feeding or any other
or invasive diagnostic tests.
artificial or invasive form of
nutrition (food) or hydration (water).
I I
I I
I
DO
DO NOT
want chemotherapy.
I I
I I
I I
I I
I
DO
DO NOT
want mechanical respiration.
I
DO
DO NOT
want radiation treatment.
I realize that if I do not specifically indicate my preference regarding any of the forms of
treatment listed above, I may receive that form of treatment.
I MY HEALTH CARE AGENT, IF I HAVE APPOINTED ONE, (check only one)
______ must follow these instructions.
______ shall have final say and may override any of my instructions except:
______________________________________________________________________________________
I IF I DID NOT APPOINT A HEALTH CARE AGENT, THESE INSTRUCTIONS SHALL
BE FOLLOWED.
ORGAN DONATION
(Check Only One)
______ I consent to donate my organs and tissues at the time of my death for the purpose
of transplant, medical study or education, subject to: (Insert any limitations you desire on the
donation of specific organs or tissues or uses for donated organs and tissues).
______________________________________________________________________________________
______ I do not consent to donate my organs or tissues at the time of my death.
DECLARATION
The declarant or the person on behalf of and at the direction
of the declarant knowingly and voluntarily signed this writing
by signature or mark in my presence.
I made this declaration on the ______ day
_____________________________________
of __________________ (month, year).
Witness's signature:
_____________________________________
Witness's address:
_____________________________________
_________________________________________
Declarant's signature:
_________________________________________
_____________________________________
Witness's signature:
Declarant's address:
_____________________________________
_________________________________________
Witness's address:
_____________________________________
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