INSTRUCTIONS FOR HEALTH CARE
If you are satisfied to allow your agent to determine what is best for you in making end-
of-life decisions, you need not fill out this part of the form. If you do fill out this part of the
form, you may cross out any wording you do not want.
(7) END-OF-LIFE DECISIONS: If I am unable to make or communicate decisions
regarding my health care, and IF (i) I have an incurable or irreversible condition that will result
in my death within a relatively short time, OR (ii) I become unconscious and, to a reasonable
degree of medical certainty, I will not regain consciousness, OR (iii) the likely risks and burdens
of treatment would outweigh the expected benefits, THEN I direct that my health-care providers
and others involved in my care provide, withhold or withdraw treatment in accordance with the
choice I have initialed below in one of the following two boxes:
[____________] (a) I CHOOSE NOT to Prolong Life
I do not want my life to be prolonged.
[____________] (b) I CHOOSE To Prolong Life
I want my life to be prolonged as long as possible within the limits
of generally accepted health-care standards.
(8) ARTIFICIAL NUTRITION AND HYDRATION: If I have chosen above NOT
to prolong life, I also specify by marking my initials below:
[____________] I DO NOT want artificial nutrition OR
[____________] I DO want artificial nutrition
[____________] I DO NOT want artificial hydration unless required for my comfort OR
[____________] I DO want artificial hydration.
(9) RELIEF FROM PAIN: Regardless of the choices I have made in this form and
except as I state in the following space, I direct that the best medical care possible to keep me
clean, comfortable and free of pain or discomfort be provided at all times so that my dignity is
maintained, even if this care hastens my death:
(10) ANATOMICAL GIFT DESIGNATION: Upon my death I specify as marked
below whether I choose to make an anatomical gift of all or some of my organs or tissue:
Please Initial only one box
[____________] I CHOOSE to make an anatomical gift of all of my organs or tissue to be
determined by medical suitability at the time of death, and artificial
support may be maintained long enough for organs to be removed.