APPENDIX B3

Living Will and Health Care Proxy

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TO MY FAMILY, MY DOCTORS AND OTHERS

THERS CONCE
CONCERNED
WITH MY CARE:
I, ___________________, residing
__________________________
_____________________
esiding at ________________________
(phone _______________),
king this declaration while in full
__), am making
fu
possession of my faculties and
I do
d after long and careful consideration.
con
d
not wish to be kept alive
reasonable
ve by various measures if there is no reaso
expectation
meaningfu quality oof life.
tation of my being able to enjoy a meaningful

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should be either
pr
Accordingly, I direct that life-sustaining procedures
proc
h
withheld or withdrawn if I have
an iillness, disease or injury, or
mental deterioration,
and if doctors selected by me or
experience extreme menta
deteriora
determ that there
by my family determine
th is no reasonable expectation that I will
to enable me to enjoy a meaningful quality
t a sufficient extent
recover to
e
impossible to foresee all the circumstances in which
of life. It is obviously
obvio
I would feel
fe that this direction is applicable, but without in any way
limiting the general scope of the foregoing direction, I would certainly
limit
include (a) my being in a coma for a sufficient period, or my suffering
such brain, heart or other physical damage such that in either case
ase it is
unlikely that I would be able to perform enough bodily functions to
render my life bearable and enable me to have some
mee enjoyment out oof
life, or (b) my losing my mental faculties to thee extentt of being unable to
recognize my family and friends or my surroundings, or to understand
where I am and what I am doing,
mmunicate coherently, and
g, or to communicate
there is no reasonable expectation
tation that this situation will be reversed.

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The life-sustaining
withheld or withdrawn
ures that I would want withhe
ining procedures
withdraw
include, but
ited to, surgery, respiratory su
ut are not limited
support, artificially
ar
administered
addition, I would
ministered nutrition and hydration, and antibiotics. In ad
want cardiopulmonary resuscitation withheld, and I specifically consent
to the issuance of a Do-Not-Resuscitate
Order.
Do-Not-Resu
Order

In the circumstances described aabove, I direct that treatment be limited

too measures calculated
relieve my pain or to provide me comfort.
ca
to rel
I understand tthat these directions may result in shortening my life, but,
on thee basis
bas of my experience with others and my own self-examination,
I prefer to have my life shortened than to continue to exist without a
meaningful quality of life. I prefer it both for myself and for my loved

ones, whom I want to spare the pain and the expense that would be
involved in prolonging my life in the circumstances described.

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I have written the foregoing directions to express

ss my legal right to
refuse treatment. I recognize (a) that there mayy come a time when people
question my ability to understand what directions
ns I might then be ggiving
and their consequences, and (b) that some recent
nt court decisions have
h
required fairly specific direction.
directio as
ction. I havee therefore made these directions
inclusive and explicitt as I know how.
the
ow. Since I cannot foresee all th
specific circumstances
do
cir
mstances that can arise, I direct that if circumstances
arise thatt are not described
scribed above, the general prin
principles I have set forth
be applied in the spirit in which I have written
my family,
writte this. I expect
ex
car to regard themselves as
my doctors and others concerned with my care
with my wishes. Along
legally and morally bound to act in accordance
accorda
wish to donate any needed organs or
instructions I also wi
with the above instructions,
organization
upon my death.
d
tissues to an eligible donee
orga

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residing at _____________________
here appoint ____________,
I hereby
_
________________), as my health care agent to accept, refuse or
(pho ______
(phone
care decisions about my treatment and hospitalization in
make health
h
accordance with my wishes and instructions as stated herein or as
otherwise known to him/her. In the event that such person is unable,
unwilling or unavailable to act as my health care agent, I hereby
appoint
by appo
___________, residing at __________________________
_______ (phone
(phon
______________), as my health care agent.

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I understand that unless I revoke it,, this Living

ng Will and Health Care
Proxy will remain in effect indefinitely.
finitely.

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Signed: ___________________________
_________
__________________

Dated: ____________________________
__________________
___________________________

document is personally
I declare that the person who signed this doc
known to me and appears to be of sound mind
min and acting willingly and
signed this document
in my presence, and the
free from duress. He/she si
d
presence. I am not the person appointed as
er witnesses signed in my pre
other
agent
d
gent by this document.
Witness:_____________________
ness:_____

Address:_____________________

Witness:_____________________

Address:_____________________

Witness:_____________________

Address:_____________________

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