Living Will Or Health Care Directive (Page 2 of 2) in pdf

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LIVING WILL

TO MY FAMILY, MY PHYSICIAN, MY CLERGYMAN, MY LAWYER

Declaration

Declaration made this _________ day of _________________________, __________.

I, ______________________________________________________________, willfully and voluntarily

make known my desire that my dying not be artificially prolonged under the circumstances set forth below, and I do

hereby declare:

Designation. ___________________________________________________ of ___________________,

____________, is hereby designated as my surrogate to carry out the provision of this declaration or if I am unable

to make my own choices and my condition is not clearly covered by this document. If, for any reason, he/she

becomes unable or unwilling to so act, then ________________________________________________ of

________________________, _____________, is designated as alternate surrogate, with the same authority, rights

and obligations as the primary surrogate.

If at any time I should have a condition as identified below and if my attending physician has determined that

there can be no recovery from such condition and that my death is imminent, I direct that the following, if considered

medically reasonable, be followed.

A - Unconscious State (Permanent Vegetative State): Patient is totally unaware with little chance of ever

waking up.

B – Permanent Confusion: Patient is unable to remember, understand or make decisions. He/She does not

recognize loved ones or have a clear conversation with them.

C – Total Dependence: Patient is unable to talk clearly or move by him/herself. He/She depends on others for

feeding and hygiene. Patient’s condition cannot be helped by rehabilitation or any other means.

D – End-Stage Disease: This illness has reached its final stages in spite of full treatment. (Such as widespread

cancer or badly damaged heart and lungs)

Medical Conditions

(circle answer)

Cardiopulmonary Resuscitation: if at the point of death, using drugs and electric

Yes No Yes No Yes No Yes No

shock to keep the heart beating; artificial breathing

Mechanical Breathing: breathing by machine

Yes No Yes No Yes No Yes No

Artificial Nutrition: giving nutrition through a tube in the veins, nose, or stomach

Yes No Yes No Yes No Yes No

Artificial Hydration: giving of fluid through a tube in the veins, nose or stomach

Yes No Yes No Yes No Yes No

Major Surgery: such as removing the gall bladder or part of the intestines

Yes No Yes No Yes No Yes No

Kidney Dialysis: cleaning the blood by machine or by fluid passed through the belly

Yes No Yes No Yes No Yes No

Chemotherapy: using drugs to fight cancer

Yes No Yes No Yes No Yes No

Minor Surgery: such as removing some tissue from an infected toe

Yes No Yes No Yes No Yes No

Invasive Diagnostic Tests: such as using a flexible tube to look into the stomach

Yes No Yes No Yes No Yes No

Blood or Blood Products: such as giving transfusions

Yes No Yes No Yes No Yes No

Antibiotics: using drugs to fight infection

Yes No Yes No Yes No Yes No

Simple Diagnostic Tests: such as performing blood tests or x-rays

Yes No Yes No Yes No Yes No

Pain Medications: even if they dull consciousness and indirectly shorten my life

Yes No Yes No Yes No Yes No

In the absence of my ability to give directions regarding the use of such life-prolonging procedures, it is my

intention that this declaration be honored by my family and physician as the final expression of my legal right to

refuse medical or surgical treatment and to accept the consequences for such refusal. I hereby hold harmless my

physicians and any other health care providers who render care or withhold care from me in good faith.

If I have been diagnosed as pregnant and that diagnosis is known to my physician, this declaration shall

have no force or effect during the course of my pregnancy.

I understand the full import of this declaration, and I am emotionally and mentally competent to make this

declaration.

__________________________________

Declarant

WITNESSES:

The Declarant is known to me, and I believe him/her to be of sound mind.

__________________________________

Witness

Living Will Or Health Care Directive Page 2

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