I, __________________________________, being
of sound mind, make this statement as a directive to be followed if
I become permanently unable to participate in decisions regarding my
Medical care. These instructions reflect my firm and settled
commitment to decline medical treatment under the circumstances
I direct my attending physician and other
medical personnel to withhold or withdraw treatment that serves only
to prolong the process of my dying, if I should be in an
incurable or irreversible mental or physical condition with no
reasonable expectation of recovery.
These instructions apply if I am: a) in a
terminal condition; b) permanently unconscious; or c)
if I am conscious but have irreversible brain damage and will
never regain the ability to make decisions and express my
I direct that treatment be limited to
measures to keep me comfortable and to relieve pain, including any
pain that might occur by withholding or withdrawing treatment. While
I understand that I am not legally required to be specific about
future treatments, if I am in the
condition(s) described above, I feel especially strong about the
following forms of treatment.
I do not want cardiac resuscitation.
I do not want mechanical respiration.
I do not want tube feeding.
I do not want antibiotics.
I do want maximum pain relief.
Other instructions (insert personal instructions):
I HEREBY APPOINT
as my health care agent to make all health
care decisions for me in conformity with the guidelines I have
expressed in this document. I direct my agent to make health care
decisions in accordance with my wishes and instructions as stated
above or as otherwise known to him or her. I also direct my agent to
abide by any limitations on his or her authority as stated above or
as otherwise known to him or her.
In the event my health care agent is unable,
unwilling, or unavailable to serve as such, then I appoint as my
substitute health care agent (with the same powers that I have
I understand that unless I revoke it, this
living will and health care proxy will remain in effect
These directions express my legal right to
refuse treatment, under the laws of the State of ______________. Unless I have revoked
this instrument or otherwise clearly and explicitly indicated that I
have changed my mind, it is my unequivocal intent that my
instructions as set forth in this document be faithfully carried
Statement By Witnesses (Must Be 21 or
I declare that the person who signed this document is personally known to me and appears to be of sound mind and acting of his or her own free will. He or she signed (or asked another to sign for him or her) this document in my presence.
KEEP THIS SIGNED ORIGINAL WITH YOUR PERSONAL
PAPERS AT HOME. GIVE COPIES OF THE SIGNED
ORIGINAL TO YOUR DOCTOR, FAMILY, LAWYER AND
OTHERS WHO MIGHT BE
INVOLVED IN YOUR CARE.