Stopping Treatments to Prolong My Life
Life-support treatments are used to try and keep you alive.
If I reach a point where I can no longer make decisions for myself and it is reasonably certain that I
will not recover my ability to know who I am (write initials on line if you agree):
____ I want to stop or withhold all treatments that are prolonging my life. This includes but is not
limited to tube feedings, IV (intravenous) fluids and medications, respirator/ventilator
(breathing machine), dialysis, blood products and antibiotics.
Cardiopulmonary Resuscitation (CPR)
CPR is a treatment used to attempt to restore heart rhythm and breathing when they have stopped.
It may include chest compressions, medicines, electrical shocks, and a breathing tube. I understand
that CPR can save a life. I also understand that it does not work as well for people who have chronic
(long-term) health problems and/or an illness that can no longer be treated.
My CPR choice listed below may be reconsidered by my health care agent in light of my other
instructions or new medical information. My health care agent may act on my behalf if I cannot make
my own choices.
If I do not want CPR tried, my doctor should be told about my choice. If I show below that I do not
want CPR, I understand this choice alone will not stop emergency workers from attempting CPR in an
emergency. Other papers may be needed to control the actions of emergency workers.
Select one option. Mark with your initials.
____ I want CPR attempted if my heart stops or if I stop breathing.
____ I want CPR attempted if my heart stops or if I stop breathing unless my doctor decides any one
of the following:
I have an untreatable illness or injury and am dying; OR
I have little chance of surviving; OR
I have little chance of living much longer and the process of CPR would cause me
____ I do not want CPR attempted if my heart stops or if I stop breathing. Rather, I want my death to