Advance Directive For A Natural Death Form ("Living Will") (Page 2 of 5) in pdf

Advance Directive For A Natural Death Form ("Living Will") Page 2

These are My Directives about Prolonging My Life:

In those situations I have initialed in Section 1, I direct that my health care providers:

NOTE: INITIAL ONLY IN ONE PLACE.

may withhold or withdraw life-prolonging measures.

(Initial)

shall withhold or withdraw life-prolonging measures.

(Initial)

Exceptions –– "Artificial Nutrition or Hydration"

NOTE: INITIAL ONLY IF YOU WANT TO MAKE EXCEPTIONS TO YOUR INSTRUCTIONS IN

PARAGRAPH 2.

EVEN THOUGH I do not want my life prolonged in those situations I have initialed in Section 1:

I DO want to receive BOTH artificial hydration AND artificial nutrition (for

example, through tubes) in those situations.

(Initial)

NOTE: DO NOT INITIAL THIS BLOCK IF ONE OF THE BLOCKS BELOW

IS INITIALED.

I DO want to receive ONLY artificial hydration (for example, through tubes) in

those situations.

(Initial)

NOTE: DO NOT INITIAL THE BLOCK ABOVE OR BELOW IF THIS

BLOCK IS INITIALED.

I DO want to receive ONLY artificial nutrition (for example, through tubes) in

those situations.

(Initial)

NOTE: DO NOT INITIAL EITHER OF THE TWO BLOCKS ABOVE IF THIS

BLOCK IS INITIALED.

I Wish to be Made as Comfortable as Possible

I direct that my health care providers take reasonable steps to keep me as clean, comfortable,

and free of pain as possible so that my dignity is maintained, even though this care may hasten

my death.

I Understand my Advance Directive

I am aware and understand that this document directs certain life-prolonging measures to be

withheld or discontinued in accordance with my advance instructions.

Advance Directive For A Natural Death Form ("Living Will") Page 2