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CONDITIONS
UNDER WHICH YOU MAY EXECUTE A LIVING WILL (ADVANCE DIRECTIVE)
 1. When the
life-sustaining treatment is experimental and not a proven therapy, or is
likely to be ineffective or futile in prolonging life, or is likely to
merely prolong an imminent dying process.
2. When you are permanently
unconscious, as determined by your attending physician and confirmed by a
second qualified physician.
3. If you are in a terminal
condition, as determined by your attending physician and confirmed by a
second qualified physician.
4. If none of the above
circumstances applies, when you have a serious irreversible illness or
condition, and the likely risks and burdens associated with the medical
intervention to be withheld or withdrawn may reasonably be judged to
outweigh the likely benefits to you from such intervention, or imposition
of the medical intervention on an unwilling patient would be inhumane.
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INFORMATION ABOUT THIS LIVING WILL |
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Election of Treatment(s)
After you have completed this form and printed it out, you will be
allowed you to check off treatments you want and don't want. Among
those are matters which relate to treatment while you are permanently
unconscious and the condition is irreversible. You will be given the
option of receiving artificial nutrition and hydration and other
treatment.
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Operative Date
Your living will becomes operative when a copy is provided to
your attending physician; and you are determined by
your attending physician to be incompetent and in a terminal condition or
in a state of permanent unconsciousness.
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Duty of Attending
Physician(s)
When your living will becomes
operative, your physician and other health care providers shall act in
accordance with its provisions. If your attending physician or other
health care provider cannot in good conscience comply with the provisions
of your living will or if the policies of the health care provider
preclude compliance, your attending physician or health care provider
shall so inform you, or, if you are incompetent, shall so inform your
agent, or, if you have not designated a health care proxy, shall so inform
your family, guardian or other representative. Your physician and
health care provider shall make every reasonable effort to assist in the
your transfer to another physician or health care provider who will comply
with your living will.
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Revocation
You may revoke your
advance directive at any time by a signed writing or by personally
informing your supervising health-care provider.
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Executing and Delivering Your Living
Will
After you have printed
out your Advance Directive, you may initial each of the above conditions
you wish to apply to you. You must then gather two witnesses for
signing. A designated health care representative shall not act as a
witness. ALTERNATIVELY, you may appear before a notary
public, attorney at
law or other officer authorized to administer oaths for signing. After your Advance
Directive is fully executed, you must give it to your physician to sign
the Do Not Resuscitate Order on the bottom and make this document a part
of your medical records.
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