New York Living Will

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NEW YORK LIVING WILL
I, __________________________________, being of sound mind, make this statement as a
directive to be followed if I become permanently unable to participate in decisions regarding my
Medical care. These instructions reflect my firm and settled commitment to decline medical
treatment under the circumstances indicated below.
I direct my attending physician and other medical personnel to withhold or withdraw treatment that
serves only to prolong the process of my dying, if I should be in an incurable or irreversible mental
or physical condition with no reasonable expectation of recovery.
These instructions apply if I am: a) in a terminal condition; b) permanently unconscious; or c) if I
am conscious but have irreversible brain damage and will never regain the ability to make decisions
and express my wishes.
I direct that treatment be limited to measures to keep me comfortable and to relieve pain, including
any pain that might occur by withholding or withdrawing treatment. While I understand that I am
not legally required to be specific about future treatments, if I am in the condition(s) described
above, I feel especially strong about the following forms of treatment.
I do not want cardiac resuscitation.
I do not want mechanical respiration.
I do not want tube feeding.
I do not want antibiotics.
I do want maximum pain relief.
Other instructions (insert personal instructions):
I HEREBY APPOINT
Name:
Address:
Phone Number:

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