LIVING WILL or HEALTH CARE INSTRUCTIONS
If the time comes when I am incapacitated to the point when I can no longer actively take part in
decisions for my own life, and am unable to direct my physician as to my own medical care, I
wish this statement to stand as a statement of my wishes.
I, ________________________________, the author of this document, request that, if my
condition is deemed terminal or if I am determined to be permanently unconscious, I be
allowed to die and not be kept alive through life support systems.
By terminal condition, I mean that I have an incurable or irreversible medical condition which,
without the administration of life support systems, will, in the opinion of my attending physician,
result in death within a relatively short time. By permanently unconscious I mean that I am in a
permanent coma or persistent vegetative state which is an irreversible condition in which I am at
no time aware of myself or the environment and show no behavioral response to the
Listed below are my instructions regarding particular types of life support systems. This list is not
all-inclusive. My general statement that I not be kept alive through life support systems provided
to me is limited only where I have indicated that I desire a particular treatment to be provided.
Artificial Respiration (including a respirator)
Artificial means of providing nutrition and hydration
Other specific requests: _________________________________________________________