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Living Will

Advance Directive: Treatment Preferences (“Living Will”) - You have the right to use an advance directive to say what you want about future life-sustaining treatment issues.  It lets you decide about life-sustaining procedures in three situations: when death from a terminal condition is imminent despite the application of life-sustaining procedures; a condition of permanent unconsciousness called a persistent vegetative state; and end-stage condition, which is an advanced, progressive, and incurable condition resulting in complete physical dependency.  You may complete all or only part of the forms that you use. Different forms may also be used.

     

A.  Preference in Case of Terminal Condition

 

(If you want to state what your preference is, initial one only. If you do not want to state a preference here, cross through the whole section.)

           

If my doctors certify that my death from a terminal condition is imminent, even if life-sustaining procedures are used:

 

[    ] _____ 1. Keep me comfortable and allow natural death to occur. I do not want any medical interventions used to try to extend my life. I do not want to receive nutrition and fluids by tube or other medical means.

 

        OR

 

[    ] _____ 2. Keep me comfortable and allow natural death to occur. I do not want medical interventions used to try to extend my life. If I am unable to take enough nourishment by mouth, however, I want to receive nutrition and fluids by tube or other medical means.

 

        OR

 

[    ] _____ 3. Try to extend my life for as long as possible, using all available interventions that in    reasonable medical judgment would prevent or delay my death. If I am unable to take enough nourishment by mouth, I want to receive nutrition and fluids by tube or other medical means.                                                                                                           

 

      B.  Preference in Case of Persistent Vegetative State

 

(If you want to state what your preference is, initial one only. If you do not want to state a preference here, cross through the whole section.)

                

If my doctors certify that I am in a persistent vegetative state, that is, if I am not conscious and am not aware of myself or my environment or able to interact with others, and there is no reasonable expectation that I will ever regain consciousness:

 

[    ] _____ 1. Keep me comfortable and allow natural death to occur. I do not want any medical interventions used to try to extend my life. I do not want to receive nutrition and fluids by tube or other medical means.

 

        OR

 

[    ] _____ 2. Keep me comfortable and allow natural death to occur. I do not want medical interventions used to try to extend my life. If I am unable to take enough nourishment by mouth, however, I want to receive nutrition and fluids by tube or other medical means.

 

        OR

 

[    ] _____ 3. Try to extend my life for as long as possible, using all available interventions that in    reasonable medical judgment would prevent or delay my death. If I am unable to take enough nourishment by mouth, I want to receive nutrition and fluids by tube or other medical means.                                                                                                          

 

      C.  Preference in Case of End-Stage Condition

 

(If you want to state what your preference is, initial one only. If you do not want to state a preference here, cross through the whole section.)

                

If my doctors certify that I am in an end-state condition, that is, an incurable condition that will continue in its course until death and that has already resulted in loss of capacity and complete physical dependency:

 

[    ] _____ 1. Keep me comfortable and allow natural death to occur. I do not want any medical interventions used to try to extend my life. I do not want to receive nutrition and fluids by tube or other medical means.

 

        OR

 

[    ] _____ 2. Keep me comfortable and allow natural death to occur. I do not want medical interventions used to try to extend my life. If I am unable to take enough nourishment by mouth, however, I want to receive nutrition and fluids by tube or other medical means.

 

        OR

 

[    ] _____ 3. Try to extend my life for as long as possible, using all available interventions that in    reasonable medical judgment would prevent or delay my death. If I am unable to take enough nourishment by mouth, I want to receive nutrition and fluids by tube or other medical means.                                                                                                          

 

      D.  Pain Relief

 

No matter what my condition, give me the medicine or other treatment I need to relieve pain.

 

      E.  In Case of Pregnancy 

 

(Optional, for women of child-bearing years only; form valid if left blank)

If I am pregnant, my decision concerning life-sustaining procedures shall be modified as follows:

_____________________________________________________________________ 

_____________________________________________________________________

_____________________________________________________________________

F.  Effect of Stated Preferences

(Read both of these statements carefully. Then, initial one only.)

 

[    ] _____ 1. I realize I cannot foresee everything that might happen after I can no longer decide for myself. My stated preferences are meant to guide whoever is making decisions on my behalf and my health care providers, but I authorize them to be flexible in applying these statements if they feel that doing so would be in my best interest.

 

        OR

 

[    ] _____ 2. I realize I cannot foresee everything that might happen after I can no longer decide for myself. Still, I want whoever is making decisions on my behalf and my health care providers to follow my stated preferences exactly as written, even if they think that some alternative is better.

 

SIGNATURES AND WITNESSES

 

By signing below as the Declarant, I indicate that I am emotionally and mentally competent to make this advance directive and that I understand its purpose and effect. I also understand that this document replaces any similar advance directive I may have completed before this date.

 

Signature of Declarant _________________________     Date ____________________

 

Print Name __________

 

 

The Declarant signed or acknowledged signing this document in my presence and, based upon personal observation, appears to be emotionally and mentally competent to make this advance directive.

 

Signature of Witness _________________________     Date ____________________

 

Print Name ________________________________

           

 

Signature of Witness _________________________     Date ____________________

 

Print Name ________________________________

 

           

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|GENERAL INSTRUCTIONS | |With a Living Will, your family members and health care providers know your |

| | |preferences about: |

|WHAT IS A LIVING WILL? | |·         Organ or tissue donation |

| | |·         Extended artificial life support |

|A Living Will is a legal document that leaves instructions about your | |·         The use of dialysis and breathing machines |

|preferences for end-of-life care and medical treatment. Unlike a traditional | |·         Resuscitation if your breathing or heartbeat stops |

|Last Will and Testament, a Living Will takes effect when you are still alive | |·         What should happen if your doctor determines there is no recovery |

|but unable to communicate your medical wishes if you ever become terminally | |·         When, if ever, would you refuse medical care |

|ill or unconscious. | | |

| | |WHAT IS INCLUDED |

|If you have an opinion on one of these questions, you would benefit from a | | |

|Living Will. | |A simple living will should generally have at least the following: |

|·         How long would you want to be on artificial life support? | | |

|·         Do you want to be resuscitated after suffering from a cardiac | |1. End-of-life preferences. If you become terminally ill or injured, a Living|

|arrest? | |Will directs your doctor to either continue or withhold life sustaining |

|·         Would you prefer to pass away “naturally” or Allow Natural Death | |treatment. |

|(AND)? | | |

|·         Are you okay with ventilators and feeding tubes but not intubation?| |2. What does it mean to be terminally ill or injured? Your doctor and another|

|·         How do you feel about patient comfort and pain management? | |doctor decide that you have a condition that cannot be cured and that you |

| | |will likely pass away in the near future from this condition. Given this |

|COMMON SITUATIONS | |unfortunate circumstance, how do you wish to be treated? |

|You may need a Living Will if you are: | | |

|·         Over the age of 18 years old | |3. What does it mean to be permanently unconscious? Your doctor and another |

|·         Military personnel being deployed overseas | |doctor (one of whom is qualified to make such a diagnosis) agree within a |

|·         Traveling abroad for an extended period of time | |reasonable degree of medical certainty that: you can no longer think, no |

|·         Undergoing surgery or will be entering the hospital for any reason | |longer feel anything, no longer knowingly move, or no longer aware of being |

|·         Diagnosed with a terminal medical condition or illness | |alive. The doctors believe that this condition will last indefinitely without|

|·         Undergoing continuous medical treatment by a physician or medical | |hope for improvement and have watched you long enough to determine that you |

|team | |are permanently unconscious. |

|·         Growing wiser and older but concerned about your current health | | |

|·         Wanting your family members know how you want to be medically | |4. What is life sustaining treatment? Life sustaining treatment includes |

|treated | |drugs, machines, or medical procedures that would help keep you alive but not|

|·         Engaged in a high risk profession (i.e. firefighter or police) | |cure you. Those who may refuse life sustaining treatment may prioritize |

|·         Creating an estate plan along with a traditional Will and Power of | |quality of life in the final days of being alive. |

|Attorney | | |

| | |5. Organ Donation. A Living Will allows you to specify whether you want to |

|WHEN IS IT NEEDED | |donate your body, organs, and/or tissues for transplantation or medical |

| | |research. The body is temporarily kept on life-sustaining treatment until |

|Living Wills are commonly used when someone wants the peace of mind that | |organs are removed for donation. Alternatively, you can specify a scientific |

|their medical and health decisions will be made according their final wishes.| |study at a local medical school or university to donate your body. |

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