New York Health Care Proxy Living Will Template printable pdf download

NEW YORK HEALTH CARE PROXY/LIVING WILL

I, ______________________, residing at _____________________________________, being of

sound mind do hereby appoint ______________________________, residing at

______________________________________, as my health care agent to make any and all health

care decisions for me except to the extent I state otherwise.

A. I hereby declare and make known to my family, physician and others, my instructions and wishes

for my future health care. I direct that all health care decisions, including decisions to accept or refuse

any treatment, service or procedure used to diagnose, treat or care for my physical or mental condition

and decisions to provide, withhold or withdraw life-sustaining measures, be made in accordance with

any wishes as expressed in this document. This instruction directive shall take effect in the event that I

become temporarily or permanently unable to make my own health care decisions, as determined by

the physician who has primary responsibility for my care, and any necessary confirming

determinations. I direct that this document become part of my permanent medical records.

B. GENERAL INSTRUCTIONS. To inform those responsible for my care of my specific wishes, I

make the following statement of personal views regarding my health care:

Initial ONE of the following two statements with which you agree:

1. __________ I direct that all medically appropriate measures be provided to sustain my

life, regardless of my physical or mental condition.

2. __________ There are circumstances in which I would not want my life to be prolonged

by further medical treatment. In these circumstances, life-sustaining measures should not be initiated

and if they have been, they should be discontinued for the purpose of allowing me to die naturally. I

recognize that this is likely to hasten my death. In the following, I specify the circumstances in which I

would choose to forego life-sustaining measures.

If you have initialed statement 2, please initial each of the statements (a, b, c) with which you

agree:

a. __________ I realize that there may come a time when I am diagnosed as having an

incurable or irreversible illness, disease or condition. If this occurs, and my attending physician and at

least one additional physician who has personally examined me determine that my condition is

terminal, I direct that life-sustaining measures which would serve only to artificially prolong my dying

be withheld or discontinued even if the result is to hasten my death. I also direct that I be given all care

necessary to make me comfortable and to relieve pain.

b. __________ If there should come a time when I become permanently unconscious, and it

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New York Health Care Proxy Living Will Template