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1. Terminal Condition Terminal condition means an incurable or irreversible condition for which the administration of medical treatment will serve only to prolong the dying process.

2. Persistent Vegetative State Persistent vegetative state means a condition that reasonable medical judgment finds constitutes complete and irreversible loss of all of the functions of the cerebral cortex and results in a complete, chronic and irreversible cessation of all cognitive functioning and consciousness and a complete lack of behavioral responses that indicate cognitive functioning, although autonomic functions continue.

3. Permanent Coma Permanent Coma means a profound state of unconsciousness caused by disease, injury, poison, or other means, from which there exists no reasonable expectation of regaining consciousness as determined by the patient's physician and one other physician.

Terminal Condition Terminal condition means an incurable or irreversible condition that, without the administration of life-prolonging treatment, will result, in the opinion of my attending physician, in my imminent death. The term does not include any form of senility, Alzeheimer's disease, mental retardation, mental illness, or chronic mental or physical impairment, including comatose conditions that will not result in imminent death.

Permanent Unconsciousness Permanent unconsciousness is when my doctor and another doctor agree that, within a reasonable degree of medical certainty, I can no longer think, feel anything, knowingly move, or be aware of being alive. They believe this condition will last indefinitely without hope for improvement and have watched me long enough to make that decision. At least one of these doctors must be qualified to make such a diagnosis.

Is there a possiblity that you are, or may in the future become pregnant?

Yes No

Terminal Condition Terminal condition means a condition from which there is no hope of recovery, and is certified as terminal by two physicians, one of whom is your attending physician, who have personally examined you and have determined that, without the use of life-sustaining procedures, your death would likely occur within a relatively short period of time.

Permanent Unconsciousness Permanent unconsciousness means a profound state of unconsciousness caused by disease, injury, poison, or other means and for which it has been determined that there exists no reasonable expectation of regaining consciousness, and includes a permanent and irreversible condition in which there is (a) The absence of voluntary action or cognitive behavior of any kind; and (b) an inability to communicate or interact purposefully with the environment.

Pregnancy

Is there a possibility that you currently are or may become pregnant in the near future?

Yes No

You can change or cancel your Living Will at any time, as long as you have mental capacity. Once you have become incapable, however, you will not be able to change your Living Will. In the next section (your Medical Power of Attorney) you will be choosing someone to be your health care representative (agent). That person will make health care decisions for you if you become incapable of making or communicating your own decisions. If you do not want your living will to be cast in stone at the moment you cease to be capable, you may give your agent the power to revoke it on your behalf.

Would you like your agent to have this power?

Yes No

A Medical Power of Attorney gives your agent the power and authority to make health care decisions for you, but does not give him or her the power to enforce the decisions you have already made for yourself (in your Living Will). If you want to, you can give your agent the power to enforce your Living Will.

Would you like your agent to have this power?

Yes No

You can change or cancel your Living Will at any time, as long as you have mental capacity. Once you have become incapable, however, you will not be able to change your Living Will. If you do not want your Living Will to be cast in stone at the moment you cease to be capable, you may decide to choose a person (called your agent) who will have the power to revoke it on your behalf.

Do you want to have an agent who can revoke this Living Will on your behalf?

Yes No

If you want, you can choose a person (called your agent) who will have the power to enforce your Living Will.

Do you want to have an agent who can enforce this Living Will on your behalf?

Yes No

Terminal Condition Terminal Condition means an incurable condition caused by injury or illness that reasonable medical judgment finds would cause death imminently, so that the application of life-sustaining procedures serves only to postpone the moment of death.

Persistent Vegetative State Persistent Vegetative State means a condition that reasonable medical judgment finds constitutes complete and irreversible loss of all of the functions of the cerebral cortex and results in a complete, chronic and irreversible cessation of all cognitive functioning and consciousness and a complete lack of behavioral responses that indicate cognitive functioning, although autonomic functions continue.

Permanent Coma Permanent Coma means a profound state of unconsciousness caused by disease, injury, poison, or other means, from which there exists no reasonable expectation of regaining consciousness as determined by the patient's physician and one other physician.

Permanent Coma

If I am in a permanent coma with no hope of recovery, I would like the following done:

Life Support:	I want all possible life prolonging procedures I DO NOT want to be kept alive by artificial life support.
Food and Water:	I want to be given food and water I DO NOT want to be given food or water
Comfort Care:	I want to be provided comfort care I DO NOT want to be given comfort care that could prolong my life

Persistent Vegetative State

If I am in a persistent vegetative state with no hope of recovery, I would like the following done:

Life Support:	I want all possible life prolonging procedures. I DO NOT want to be kept alive by artificial life support.
Tube Feeding:	I want food and water administered artificially. I DO NOT want food and water administered artificially.
Comfort Care:	I want to be provided comfort care I DO NOT want to be given comfort care that could prolong my life

Health Care Agent

You may designate a person of your choice to make treament decisions for you if you are comatose or otherwise unable to make your own decisions. This person must be at least the age of majority for your jurisdiction and should not be any of the following: a treating health care provider, a non-relative employee of your treating health care provider, an operator of a community care facility, or a non-relative employee of an operator of a community care facility.

Please enter the information of the person you wish to designate below:

YOU DO NOT HAVE TO APPOINT A HEALTH CARE REPRESENTATIVE.

Do you want to appoint a health care representative?

Yes No

Representative's Information

Would you like to name an Alternative Health Care Representative (recommended)?

Yes No

Authority of Health Care Proxy

If at any time you should have an incurable injury, disease, illness or condition verified to be a terminal condition by two (2) medical doctors who have examined you, and where the application of life-sustaining treatment of any kind would serve only to prolong your life, and where a medical doctor determines that you will die within six months, whether or not life-sustaining treatment is used, or you have been diagnosed as being persistently unconscious, what authority do you want your health care proxy to have?

Terminal Condition

If I have a terminal condition,

Life-sustaining Treament
	I DO NOT authorize my health care proxy to direct that life-sustaining treatment be withheld or withdrawn, even if such treatment would only prolong the process of dying.
	I authorize my health care proxy to direct that life-sustaining treatment be withheld or withdrawn if such treatment would only prolong my process of dying.

Artificial Feeding
	I DO NOT authorize my health care proxy to direct that artificially administrated nutrition or hydration be withheld or withdrawn from me unless, in the opinion of my attending physician, the artificial administration of nutrition and hydration would be harmful to me.
	I authorize my health care proxy to direct that artificially provided nutrition and hydration (food and water) be withheld or withdrawn if I have a terminal condition and can no longer chew or swallow by myself or with someone helping me.

Comfort Care
	I DO NOT authorize my health care proxy to make decisions with respect to the provision of comfort care.
	I authorize my health care proxy to direct that comfort care be withheld or withdrawn from me if it would prolong the process of dying.
	I do not wish to state a preference about the authority of my health care proxy regarding the provision of comfort care if I am in a terminal condition.

Do you want to authorize your health care proxy to do other things on your behalf if you are in a terminal condition?

Yes No

By law, your health care proxy can act on your behalf for the purpose of making health care decisions only. DO NOT authorize your health care proxy to act for any other purpose.

Persistently Unconscious

If I am persistently unconscious,

Life-sustaining Treament
	I DO NOT authorize my health care proxy to direct that life-sustaining treatment be withheld or withdrawn from me.
	I authorize my health care proxy to direct that life-sustaining treatment be withheld or withdrawn if such treatment will only serve to maintain me in an irreversible condition.

Artificial Feeding
	I DO NOT authorize my health care proxy to direct that artificially administrated nutrition or hydration be withheld or withdrawn from me unless, in the opinion of my attending physician, the artificial administration of nutrition and hydration would be harmful to me.
	I authorize my health care proxy to direct that artificially provided nutrition and hydration be withheld or withdrawn from me if I can no longer chew or swallow by myself or with someone helping me.

Comfort Care
	I DO NOT authorize my health care proxy to make decisions with respect to the provision of comfort care.
	I authorize my health care proxy to direct that comfort care be withheld or withdrawn from me if it would prolong the process of dying.
	I do not wish to state a preference about the authority of my health care proxy regarding the provision of comfort care if I am persistently unconscious.

Do you want to authorize your health care proxy to do other things on your behalf if you are persistently unconscious?

Yes No

By law, your health care proxy can act on your behalf for the purpose of making health care decisions only. DO NOT authorize your health care proxy to act for any other purpose.

Admission to Nursing Homes or Community-Based Residential Facilities

Your agent is authorized to admit you to a nursing home or community-based residential facility for short-term stays for recuperative care or respite care. If you want to authorize your agent to admit you to a nursing home or community-based residential facility for purposes other than recuperative care or respite care, check yes to the questions below. If you do NOT want to authorize your agent to admit you to a nursing home or community-based residential facility for purposes other than recuperative care or respite care, choose "No" to the questions below.

Do you want to authorize your agent to admit you to a nursing home for a purpose other than recuperative care or respite care?

Yes No

Do you want to authorize your agent to admit you to a community-based residential facility for a purpose other than recuperative care or respite care?

Yes No

Provision of a Feeding Tube

Check "Yes" below to authorize your health care agent to have a feeding tube withheld or withdrawn from you, unless your physician has advised that, in his or her professional judgment, this will cause you pain or will reduce your comfort.

Check "No" below if you do NOT want to give your agent authority to have a feeding tube withheld or withdrawn from you, unless the provision of the nutrition or hydration is medically contraindicated.

Yes No

Statement of Desires, Special Provisions or Limitations

Do you have any other desires or concerns regarding your health care that you want your health care agent to take notice of?

Yes No

Anatomical Gifts

Please check the statement that reflects your wishes regarding the donation of organs or parts upon death.

Note: If this choice revokes a prior commitment that you have made to make an anotomical gift to a designated donee, you must agree to attempt to notify the donee to which or to whom you agreed to donate. (This note is not applicable if you choose not to make a statement about anatomical gifts.)

	Upon my death, I wish to donate only the following organs or parts...
	Upon my death, I wish to donate any needed organ or part.
	Upon my death, I wish to donate my body for anatomical study if needed.
	Upon my death, I refuse to make an anatomical gift.
	I do not wish to make a statement regarding anatomical gifts upon death.

Do you want to give your agent the power to make a Health Care Directive on your behalf after you have become too ill to direct your own care?

Yes No

Do you want to authorize your agent to consent to the donation of all or any of your tissue or organs for purposes of transplantation?

Yes No

Agent's Authority

Your agent's authority begins when you become incapable of directing your own health care. During your incapacity your agent will be given access to your health records and will be authorized to sign releases or other necessary documents on your behalf. At any time you are capable of making your own decisions, you may do so. Your agent will not have authority to act for you in matters unrelated to your health care.

Please make sure you have read the entire document (including the disclosure statement located at the top of the document) before signing, to make sure your wishes are expressed the way you want them to be.

Here are my desires about my health care if my doctor and another knowledgeable doctor confirm that I am in a medical condition described below:

1. Close to Death

If I am close to death and life support would only postpone the moment of my death:

A. INITIAL ONE:

____ I want to receive tube feeding.
____ I want tube feeding only as my physician recommends.
____ I DO NOT WANT tube feeding.


B. INITIAL ONE:

____ I want any other life support that may apply.
____ I want life support only as my physician recommends.
____ I want NO life support.

2. Permanently Unconscious

If I am unconscious and it is very unlikely that I will ever become conscious again:

A. INITIAL ONE:

____ I want to receive tube feeding.
____ I want tube feeding only as my physician recommends.
____ I DO NOT WANT tube feeding.


B. INITIAL ONE:

____ I want any other life support that may apply.
____ I want life support only as my physician recommends.
____ I want NO life support.

3. Advanced Progressive Illness

If I have a progressive illness that will be fatal and is in an advanced stage, and I am consistently and permanently unable to communicate by any means, swallow food and water safely, care for myself and recognize my family and other people, and it is very unlikely that my condition will substantially improve:

A. INITIAL ONE:

____ I want to receive tube feeding.
____ I want tube feeding only as my physician recommends.
____ I DO NOT WANT tube feeding.


B. INITIAL ONE:

____ I want any other life support that may apply.
____ I want life support only as my physician recommends.
____ I want NO life support.

4. Extraordinary Suffering

If life support would not help my medical condition and would make me suffer permanent and severe pain:

A. INITIAL ONE:

____ I want to receive tube feeding.
____ I want tube feeding only as my physician recommends.
____ I DO NOT WANT tube feeding.


B. INITIAL ONE:

____ I want any other life support that may apply.
____ I want life support only as my physician recommends.
____ I want NO life support.

5. General Instruction

____	I do not want my life to be prolonged by life support. I also do not want tube feeding as life support. I want my doctors to allow me to die naturally if my doctor and another knowledgeable doctor confirm I am in any of the medical conditions listed in Items 1 to 4 above.

Pregnancy

Is there a possibility that you are currently or may become pregnant in the future?

Yes No

Do you want to donate your entire body after death?

Yes No

If you are pregnant do you want your directive to be ignored until after the pregnancy ends?

Yes No

Type your directive in your own words below: