Fillable Living Will Form (Page 6 of 10) in pdf

ADVANCE DIRECTIVES OF ________________________________________

To Any Physician Who Is Treating Me, this document contains the following:

1. My Living Will or Health Care Instructions

2. My Appointment of A Health Care Agent

3. My Appointment of An Attorney-in-Fact For Health Care Decisions

4. The Designation of My Conservator Of The Person For My Future Incapacity

5. My Document of Anatomical Gift

As my physician, you may rely on any information provided by my health care agent and decisions made by my attorney-in-

fact for health care decisions or conservator of my person, if I am unable to make a decision for myself.

LIVING WILL or HEALTH CARE INSTRUCTIONS

If the time comes when I am incapacitated to the point when I can no longer actively take part in decisions for my own life,

and am unable to direct my physician as to my own medical care, I wish this statement to stand as a testament of my wishes.

I, ________________________________, the author of this document, request that, if my condition is deemed terminal or if

I am determined to be permanently unconscious, I be allowed to die and not be kept alive through life support systems. By

terminal condition, I mean that I have an incurable or irreversible medical condition which, without the administration of life

support systems, will, in the opinion of my attending physician, result in death within a relatively short time. By permanently

unconscious I mean that I am in a permanent coma or persistent vegetative state which is an irreversible condition in which I

am at no time aware of myself or the environment and show no behavioral response to the environment.

Specific Instructions

Listed below are my instructions regarding particular types of life support systems. This list is not all-inclusive. My general

statement that I not be kept alive through life support systems provided to me is limited only where I have indicated that I

desire a particular treatment to be provided.

Provide

Withhold

Cardiopulmonary Resuscitation

_________________

Artificial Respiration (including a respirator)

_________________

Artificial means of providing nutrition and hydration

_________________

__________________________________________

_________________

__________________________________________

_________________

Other specific requests:

___________________________________________________________________________________________________

____________________________________________________________________________________________________

I do want sufficient pain medication to maintain my physical comfort. I do not intend any direct taking of my life, but only

that my dying not be unreasonably prolonged.

THIS IS A SAMPLE AND OFFERED SOLELY FOR THE ASSISTANCE OF ATTORNEYS WHO WILL BE RESPONSIBLE FOR THE

ULTIMATE SUBSTANCE AND WORDING OF THE DOCUMENT. THE USE OF THIS SAMPLE BY PARTIES OTHER THAN ATTORNEYS

IS NOT AUTHORIZED

Living Will Form Page 6