Health Care Directive (Living Will)

Page 1 of 2 SW 0229 | JUL 05
HEALTH CARE DIRECTIVE (LIVING WILL)
I, want everyone who cares for me to know what health care I want,
when I cannot let others know what I want.
SECTION 1:
I want my doctor to try treatments that may get me back to an acceptable quality of life. However, if my quality of life
becomes unacceptable to me and my condition will not improve (is irreversible), I direct that all treatments that extend
my life be withdrawn.
A quality of life that is unacceptable to me means (check all that apply):
Unconscious (chronic coma or persistent vegetative state)
Unable to communicate my needs
Unable to recognize family or friends
Total or near total dependence on others for care
Other:
Check only one:
Even if I have the quality of life described above, I still wish to be treated with food and water by tube or
intravenously (IV).
If I have the quality of life described above, I do NOT wish to be treated with food and water by tube or
intravenously (IV).
SECTION 2: (You may leave this section blank.)
Some people do not want certain treatments under any circumstance, even if they might recover.
Check the treatments below that you do not want under any circumstances:
Cardiopulmonary Resuscitation (CPR)
Ventilation (breathing machine)
Feeding tube
Dialysis
Other:
SECTION 3:
When I am near death, it is important to me that:
(Such as hospice care, place of death, funeral arrangements, cremation or burial preferences.)
BE SURE TO SIGN PAGE TWO OF THIS FORM
If you only want a Health Care (Medical) Power of Attorney, draw a large X through this page.
Talk about this form with the person you have chosen to make decisions for you, your doctor(s), your family and
friends. Give each of them a copy of this form.
Take a copy of this with you whenever you go to the hospital or on a trip.
You should review this form often.
You can cancel or change this form at any time.
FOR MORE INFORMATION CONTACT HEALTH CARE DECISIONS, (602) 222-2229 OR WWW.HCDECISIONS.ORG
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