LIVING WILL AND DURABLE POWER OF ATTORNEY FOR HEALTH CARE
Date of Directive:
Name of person executing Directive:
Address of person executing Directive:
A Living Will
A Directive to Withhold or to Provide Treatment
1. I willfully and voluntarily make known my desire that my life shall not be
prolonged artificially under the circumstances set forth below. This Directive
shall be effective only if I am unable to communicate my instructions and:
a. I have an incurable or irreversible injury, disease, illness or condition, and
a medical doctor who has examined me has certified:
1. That such injury, disease, illness or condition is terminal; and
2. That the application of artificial life-sustaining procedures would
serve only to prolong artificially my life; and
3. That my death is imminent, whether or not artificial life-sustaining
procedures are utilized.
b. I have been diagnosed as being in a persistent vegetative state.
In such event, I direct that the following marked expression of my intent be followed and
that I receive any medical treatment or care that may be required to keep me free of
pain or distress.
box and initial the line after such box:
I direct that all medical treatment, care, and procedures necessary
to restore my health and sustain my life be provided to me. Nutrition and
hydration, whether artificial or non-artificial, shall not be withheld or withdrawn
from me if I would likely die primarily from malnutrition or dehydration rather than
from my injury, disease, illness or condition.