Advance Directive Page 5
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7PART C: HEALTH CARE INSTRUCTIONS (CONTINUED)
3. Advanced Progressive Illness. If I have a progressive illness that will be fatal and is in an advanced
stage, and I am consistently and permanently unable to communicate by any means, swallow food
and water safely, care for myself and recognize my family and other people, and it is very unlikely
that my condition will substantially improve:
A. INITIAL ONE:
_______ I want to receive tube feeding.
_______ I want tube feeding only as my physician recommends.
_______ I DO NOT WANT tube feeding.
B. INITIAL ONE:
_______ I want any other life support that may apply.
_______ I want life support only as my physician recommends.
_______ I want NO life support.
4. Extraordinary Suffering. If life support would not help my medical condition and would make
me suffer permanent and severe pain:
A. INITIAL ONE:
_______ I want to receive tube feeding.
_______ I want tube feeding only as my physician recommends.
_______ I DO NOT WANT tube feeding.
B. INITIAL ONE:
_______I want any other life support that may apply.
_______I want life support only as my physician recommends.
_______I want NO life support.
5. General Instruction.
INITIAL IF THIS APPLIES:
_______ I do not want my life to be prolonged by life support. I also do not want tube feeding
as life support. I want my doctors to allow me to die naturally if my doctor and another knowledgeable
doctor confirm I am in any of the medical conditions listed in Items 1 to 4 above.
6. Additional Conditions or Instructions. (Insert description of what you want done.)
______________________________________________________________________________
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