Living Will And Durable Power Of Attorney For Health Care
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C
IVING
ILL AND
URABLE
OWER OF
TTORNEY FOR
EALTH
ARE
Date of Directive:
Name of person executing Directive:
Address of person executing Directive:
A Living Will
A Directive to Withhold or to Provide Treatment
1.
I willfully and voluntarily make known my desire that my life shall not be
prolonged artificially under the circumstances set forth below. This Directive
shall be effective only if I am unable to communicate my instructions and:
a.
I have an incurable or irreversible injury, disease, illness or condition, and
a medical doctor who has examined me has certified:
1.
That such injury, disease, illness or condition is terminal; and
2.
That the application of artificial life-sustaining procedures would
serve only to prolong artificially my life; and
3.
That my death is imminent, whether or not artificial life-sustaining
procedures are utilized.
OR
b.
I have been diagnosed as being in a persistent vegetative state.
In such event, I direct that the following marked expression of my intent be followed and
that I receive any medical treatment or care that may be required to keep me free of
pain or distress.
Check one box and initial the line after such box:
I direct that all medical treatment, care, and procedures necessary
to restore my health and sustain my life be provided to me.
Nutrition and
hydration, whether artificial or non-artificial, shall not be withheld or withdrawn
from me if I would likely die primarily from malnutrition or dehydration rather than
from my injury, disease, illness or condition.
OR
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