Living Will Or Health Care Instructions Form/witnesses' Statements Form/witnesses' Affidavits Form printable pdf download

LIVING WILL or HEALTH CARE INSTRUCTIONS

If the time comes when I am incapacitated to the point when I can no longer actively take part in

decisions for my own life, and am unable to direct my physician as to my own medical care, I

wish this statement to stand as a statement of my wishes.

I, ________________________________, the author of this document, request that, if my

condition is deemed terminal or if I am determined to be permanently unconscious, I be

allowed to die and not be kept alive through life support systems.

By terminal condition, I mean that I have an incurable or irreversible medical condition which,

without the administration of life support systems, will, in the opinion of my attending physician,

result in death within a relatively short time. By permanently unconscious I mean that I am in a

permanent coma or persistent vegetative state which is an irreversible condition in which I am at

no time aware of myself or the environment and show no behavioral response to the

environment.

Specific Instructions

Listed below are my instructions regarding particular types of life support systems. This list is not

all-inclusive. My general statement that I not be kept alive through life support systems provided

to me is limited only where I have indicated that I desire a particular treatment to be provided.

Provide

Withhold

Cardiopulmonary Resuscitation

__________________________

Artificial Respiration (including a respirator)

__________________________

Artificial means of providing nutrition and hydration

__________________________

________________________________________

__________________________

________________________________________

__________________________

Other specific requests: _________________________________________________________

____________________________________________________________________________

I do want sufficient pain medication to maintain my physical comfort. I do not intend any

direct taking of my life, but only that my dying not be unreasonably prolonged.

This request is made, after careful reflection, while I am of sound mind.

______ / ______ / ______ (Date)

X______________________________

Living Will Or Health Care Instructions Form/witnesses' Statements Form/witnesses' Affidavits Form