Living Will Declaration Page 3
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3• If my physician believes that a certain life-prolonging procedure or other health care treatment may provide
me with comfort, relieve pain or lead to a significant recovery, I direct my physician to try the treatment for
a reasonable period of time. However, if such treatment proves to be ineffective, I direct the treatment be
withdrawn even if so doing shortens my life.
• I direct I be given health care treatment to relieve pain or to provide comfort even if such treatment might
shorten my life, suppress my appetite or my breathing, or be habit-forming.
• I make other instructions as follows: (you may want to describe what an acceptable quality of life is)
______________________________________________________________________________________
______________________________________________________________________________________
I have discussed my wishes with the following person(s) and authorize my physician to discuss my treatment
and this document with them: (if you have used a Medical Durable Power of Attorney to appoint an agent,
initial here____________and include that person on the first line below.)
___________________________________________________________________________
Name (Agent), Address, Telephone
___________________________________________________________________________
Name, Address, Telephone
I have read these instructions and have given them careful consideration. As I have indicated, they are in
accordance with my wishes.
Date__________________________________Signed________________________________
______________________________
Witness
______________________________
Witness
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