Ohio Durable Power Of Attorney For Health Care Will To Live Form (Page 3 of 7) in pdf

health care provider(s), utilizing the most current diagnoses and/or prognoses of my medical

condition, in the following situations with the written special instructions.

WHEN MY DEATH IS IMMINENT

A. If I have an incurable terminal illness or injury, and I will die imminently – meaning that a

reasonably prudent physician, knowledgeable about the case and the treatment possibilities with

respect to the medical conditions involved, would judge that I will live only a week or less even

if lifesaving treatment or care is provided to me – the following may be withheld or withdrawn:

(Be as specific as possible; SEE SUGGESTIONS.):

______________________________________________________________________________

(Cross off any remaining blank lines.)

WHEN I AM TERMINALLY ILL

B. Final Stage of Terminal Condition. If I have an incurable terminal illness or injury and even

though death is not imminent I am in the final stage of that terminal condition – meaning that a

reasonably prudent physician, knowledgeable about the case and the treatment possibilities with

respect to the medical conditions involved, would judge that I will live only three months or less,

even if lifesaving treatment or care is provided to me – the following may be withheld or

withdrawn:

(Be as specific as possible; SEE SUGGESTIONS.):

______________________________________________________________________________

(Cross off any remaining blank lines.)

C. OTHER SPECIAL CONDITIONS:

(Be as specific as possible; SEE SUGGESTIONS.):

______________________________________________________________________________

(Cross off any remaining blank lines.)

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