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IF I AM PREGNANT
D. Special Instructions for Pregnancy. If I am pregnant, I direct my health care provider(s) and
health care agent(s) to use all lifesaving procedures for myself with none of the above special
conditions applying if there is a chance that prolonging my life might allow my child to be born
alive. I also direct that lifesaving procedures be used even if I am legally determined to be brain
dead if there is a chance that doing so might allow my child to be born alive. Except as I specify
by writing my signature in the box below, no one is authorized to consent to any procedure for
me that would result in the death of my unborn child.
If I am pregnant, and I am not in the final stage of a terminal condition as defined above,
medical procedures required to prevent my death are authorized even if they may result in the
death of my unborn child provided every possible effort is made to preserve both my life and the
life of my unborn child.
Signature of Declarant
Signed this _________ day of _________________, 20______.
The declarant voluntarily signed this writing in my presence.
First Witness Signature:__________________________________________________________
Second Witness Signature:________________________________________________________
Form Prepared 2005