LIVING WILL DECLARATION
being of sound mind, willfully and voluntarily make this declaration to be followed if I become incompetent or otherwise incapable of expressing my decision concerning my medical treatment. This declaration reflects my firm and settled commitment to refuse life-sustaining treatment under the circumstances indicated below.
I direct my attending physician, or whomever may be involved in such a decision, to withhold or withdraw life-sustaining treatment that serves only to prolong the process of my dying, if I should be in a terminal condition, a persistent vegetative state, irreversible coma or in a state of permanent unconsciousness.
Unless I indicate to the contrary in the paragraphs below, I direct that treatment be limited to measures to keep me comfortable and to relieve pain, including any pain that might occur by withholding or withdrawing life-sustaining treatment.
In addition, if I am in the condition described above, I hereby make the following advance directions about the following forms of treatment:
I DO/DO NOT want cardiac resuscitation or a cardiac pacemaker.
I DO/DO NOT want blood or blood products.
I DO/DO NOT want tube feeding or any other artificial or invasive form of nutrition (food) or hydration (water).
I DO/DO NOT want mechanical respiration.
I DO/DO NOT want kidney dialysis.
I DO/DO NOT want antibiotics.
I DO/DO NOT want any form of surgery or invasive diagnostic tests.
I DO/DO NOT want receipt of an organ.
I realize that if I do not specifically indicate my preference regarding any of the forms of treatment listed above, I may receive that form of treatment.
I DO/DO NOT want to designate another person as my surrogate to make medical treatment decisions for me if I should become incompetent and in a terminal condition or in a state of permanent unconsciousness.
Name of surrogate (if applicable):
The declarant or the person on behalf of and at the direction of the declarant knowingly and voluntarily signed this writing by signature or mark in my presence.
I made this declaration on the Declarant's address: X day of XX, 20XX.
Witness' signature Witness' signature