Advance Directive Template (Page 3 of 4) in pdf

sustaining treatments are started, I want them stopped.

_____ I want life-sustaining treatments that my doctors think are best for me.

_____ Other wishes: ___________________________________________________

Artificial Nutrition and Hydration

_____ I do not want artificial nutrition and hydration started if it would be the main

treatment keeping me alive. If artificial nutrition and hydration is strated, I want it

stopped.

______ I want artificial nutrition and hydration even if it is the main treatment

keeping me alive.

______ Other wishes: __________________________________________________

Comfort Care

______ I want to be kept as comfortable and free of pain as possible, even if such

care prolongs my dying or shortens my life.

______ Other wishes: __________________________________________________

B. These are my wishes if I am ever in a persistent vegetative state:

Life-Sustaining Treatments

_______ I do not want life-sustaining treatments (including CPR) started. If life-

sustaining treatments are started, I want them stopped.

_______ I want life-sustaining treatments that my doctors think are best for me.

_______ Other wishes:__________________________________________________

Artificial Nutrition and Hydration

_______ I do not want artificial nutrition and hydration started if it would be the main

treatment keeping me alive. If artificial nutrition and hydration is started, I want it

stopped.

_______ I want artificial nutrition and hydration even if it is the main treatment

keeping me alive.

_______ Other wishes:__________________________________________________

Comfort Care

_______ I want to be kept as comfortable and free of pain as possible even if such

care prolongs my dying or shortens my life.

_______ Other wishes: __________________________________________________

C. Other Directions

You have the right to be involved in all decisions about your medical care, even those

not dealing with terminal conditions or persistent vegetative states. If you have

wishes not covered in other parts of this document please indicate them here:

________________________________________________________________________

PART 3. OTHER WISHES

A. Organ Donation

Advance Directive Template Page 3