Health Care Directive (Living Will) (Page 3 of 4) in pdf

Health Care Directive (Living Will) Page 3

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In this section, I have placed an X in the box beside all measures for

extending life that are unacceptable to me when there is no reasonable

expectation of my recovery and which are to be withheld or withdrawn in

that case. I have initialed those measures that I would still accept even if

there is no real hope of my recovery.

(a)

resuscitation of my heart (defibrillation and chest compres-

sion).

(b)

artificial supportive breathing, except for the purpose of

organ donation (mechanical ventilation on a respirator)

(c)

dialysis to replace kidney function.

(d)

Surgical procedures.

(e)

radiation

(f)

chemotherapy

(g)

medications other than those used for comfort

(h)

blood transfusion

(i)

diagnostic tests

(j)

special feeding, whether food into the vein (parenteral) or

tube feeding into the stomach (enteral).

If I should happen to be under the care of a physician who cannot respect

my wishes as expressed in this document, I direct that the physician with-

draw from my care, and that I be placed under the care of another physician

who will respect my views. Similarly, I direct that I will be transferred to

another hospital if necessary to honour the directions in this document.

No participant in the making of carrying out of this directive, whether it be

a health care provider, hospital administrator, spouse, relative, friend or any

other person, shall be held responsible in any way, legally or professionally,

for any consequences arising from the implementation of my wishes.

This directive shall have no force and effect if revoke by me orally or in

writing.

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Health Care Directive (Living Will) Page 3