Fillable Wyoming Advance Health Care Directive Form (Page 4 of 7) in pdf

Wyoming Advance Health Care Directive Form Page 4

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Today’s date: _________________________ Initial that you have completed the page: ______

PART 2: INSTRUCTIONS FOR HEALTH CARE

(5) End-of-Life decisions: I direct that those involved in my care provide, withhold or

withdraw treatment in accordance with the choice I have checked and initialed below

(check and initial only one option):

Check

Initial

___

(a) Choice to Prolong Life: I want my life to be prolonged as long as

possible within the limits of generally accepted health care standards.

___

(b) Choice Not to Prolong Life: I do not want my life to be prolonged if:

(i)

I have an incurable and irreversible condition that will

result in my death within a relatively short time;

(ii)

I become unconscious and, to a reasonable degree of

medical certainty, I will not regain consciousness;

(iii)

The likely risks and burdens of treatment would

outweigh the expected benefits.

(6) Artificial nutrition and hydration: Artificial nutrition and hydration must be

provided, withheld or withdrawn in accordance with the choice I have made in

paragraph (5) unless I have checked and initialed one of the boxes below:

Check

Initial

___

I want artificial nutrition regardless of my condition.

___

I do NOT want artificial nutrition regardless of my condition.

___

I want artificial hydration regardless of my condition.

___

I do NOT want artificial hydration regardless of my condition.

Wyoming Advance Health Care Directive Form Page 4

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