HEALTH CARE DIRECTIVE
Directive made this _______________________________ day of _________ , ______________ .
I, _____________________________________________ being of sound mind, willfully, and voluntarily make known my desire that my dying
shall not be artificially prolonged under the circumstances set forth below, and do hereby declare that:
(A) If at any time I should have an incurable and irreversible condition certified to be a terminal condition by my attend-
ing physician, and where the application of life-sustaining treatment would serve only to artificially prolong the
process of my dying, I direct that such treatment be withheld or withdrawn, and that I be permitted to die naturally.
I understand “terminal condition” means an incurable and irreversible condition caused by injury, disease or illness
that would, within reasonable medical judgment, cause death within a reasonable period of time in accordance with
accepted medical standards.
(B) If I should be in an irreversible coma or persistent vegetative state, or other permanent unconscious condition as
certified by two physicians, and from which those physicians believe that I have no reasonable probability of recovery,
I direct that life-sustaining treatment be withheld or withdrawn.
(C) If I am diagnosed to be in a terminal or permanent unconscious condition, [Choose one]
I want _________ do not want _________
artificially administered nutrition and hydration to be withdrawn or withheld the same as other forms of life-sustain-
ing treatment. I understand artificially administered nutrition and hydration is a form of life-sustaining treatment in
certain circumstances. I request all health care providers who care for me to honor this directive.
(D) In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention
that this directive shall be honored by my family, physicians and other health care providers as the final expression of
my fundamental right to refuse medical or surgical treatment, and also honored by any person appointed to make
these decisions for me, whether by durable power of attorney or otherwise. I accept the consequences of such refusal.
(E) If I have been diagnosed as pregnant and that diagnosis is known to my physician, this directive shall have no force or
effect during the course of my pregnancy.
(F) I understand the full import of this directive and I am emotionally and mentally competent to make this directive. I
also understand that I may amend or revoke this directive at any time.
(G) I make the following additional directions regarding my care:
The declarer has been personally known to me and I believe him or her to be of sound mind. In addition, I am
not the attending physician, an employee of the attending physician or health care facility in which the declarer is
a patient, or any person who has a claim against any portion of the estate of the declarer upon the declarer’s
decease at the time of the execution of the directive.