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END-OF-LIFE TREATMENT CLAUSES

Choose the clauses that apply to you and insert them into your living will, or you may write your own.

A.  I choose not to give any instructions.

My decision maker is familiar with my values, wishes, and beliefs and will follow them, so I am not giving any specific instructions about end-of-life treatment or any other issues in this document.

B.   I do not want treatment if: (select one)

a.   it will leave me in a condition of permanent unconsciousness, or

b.   it will leave me in a condition of limited consciousness and I will be unable to think or communicate with others, or

c.   it will leave me with only some ability to think or communicate and the risks of the treatment are greater than the benefits.

C.   I want my life to be prolonged as long as possible.

D.  If I am suffering from a terminal condition: (check applicable boxes)

Treatment

I want

I do not want

Cardiac resuscitation

 

 

Mechanical resuscitation

 

 

Tube feeding

 

 

Hydration

 

 

Blood or blood products

 

 

Invasive surgery and tests

 

 

Antibiotics

 

 

                       

E.   If I am permanently unconscious: (check applicable boxes)

Treatment

I want

I do not want

Cardiac resuscitation

 

 

Mechanical resuscitation

 

 

Tube feeding

 

 

Hydration

 

 

Blood or blood products

 

 

Invasive surgery and tests

 

 

Antibiotics

 

 

 

F.   If I am in a persistent vegetative condition: (check applicable boxes)

Treatment

I want

I do not want

Cardiac resuscitation

 

 

Mechanical resuscitation

 

 

Tube feeding

 

 

Hydration

 

 

Blood or blood products

 

 

Invasive surgery and tests

 

 

Antibiotics