I, ________________________________, being of sound mind, willfully and voluntarily make this declaration to be followed if I become dependent. This declaration reflects my firm and settled commitment to refuse life-sustaining treatment under the circumstances indicated below.

I direct my attending physician to withhold or withdraw life-sustaining treatment that serves only to prolong the process of my dying if I should be in terminal condition or in a state of permanent unconsciousness.

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 feel especially strongly about the following forms of treatment (please circle your response:

-- Cardiopulmonary Resuscitation (CPR)       I WANT    I DO NOT WANT
(The use of drugs and/or electric shock to    
start the heart beating and artificial breathing)
-- Mechanical Respiration (Breathing by        I WANT    I DO NOT WANT
machine)
-- Tube Feeding  (Artificial, invasive               I WANT    I DO NOT WANT
form of food given through a tube in the
veins, nose or stomach)
-- Artificial Hydration                                         I WANT    I DO NOT WANT
(Artificial, invasive form of liquids
given through a tube in the veins,
nose or stomach)
-- Blood or Blood Products                              I WANT    I DO NOT WANT
(The use of whole blood or parts of the
blood to replace blood lost)
-- Surgery (Use of any form of surgery          I WANT    I DO NOT WANT
to remove or repair any part of the body)
-- Invasive Diagnostic Tests (Tests that         I WANT    I DO NOT WANT
help reach a diagnosis by entering the
body in some way,. i.e. a tube inserted
to look at the stomach, etc)
-- Kidney Dialysis (Machine used to                I WANT    I DO NOT WANT
cleanse the blood of toxic waste
because the kidneys are unable to
do so on their own)
-- Antibiotics (Medicine given to                      I WANT    I DO NOT WANT
treat or prevent an infection)

-- Other                                                              
________________________________________________________I WANT    I DO NOT WANT

________________________________________________________I WANT    I DO NOT WANT

________________________________________________________I WANT    I DO NOT WANT
 

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.

SURROGATE OPTION (PROXY)

I (do) (do not) want to designate another person as my surrogate to make medical treatment decisions for me if I should be incompetent and in a terminal condition or in a state of permanent unconsciousness.

SURROGATE’S NAME: _____________________________________

ADDRESS: _________________________________________________

____________________________________________________________

SUBSTITUTE SURROGATE (If surrogate above is unable to serve):

NAME: ____________________________________________________

ADDRESS: _________________________________________________

____________________________________________________________

I made this declaration on the __________ day of _________,________

DECLARANT’S SIGNATURE: ________________________________

ADDRESS: __________________________________________________

_____________________________________________________________

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 the presence of the witness(s) whose signature appears below. The declarant appeared lucid, rational and of sound mind.

WITNESS’ SIGNATURE: ______________________________________

ADDRESS: ___________________________________________________

_____________________________________________________________

WITNESS’ SIGNATURE: ______________________________________

ADDRESS: ________________________________________________