LIVING WILL DECLARATION

TO MY FAMILY, HEALTH CARE PROVIDER, AND ALL THOSE CONCERNED WITH MY CARE:

I, [NAME] direct you to follow my wishes for care if I am in a terminal condition, my death is imminent, and I am unable to communicate my decisions about my medical care.

With respect to any life-sustaining treatment, I direct the following:

[INITIALS] If my death is imminent or I am permanently unconscious, I choose not to prolong my life. If life sustaining treatment has been started, stop it, but keep me comfortable and control my pain.
[INITIALS] Even if my death is imminent or I am permanently unconscious, I choose to prolong my life.
[INITIALS] I choose neither of the above options, and here are my instructions should I become terminally ill and my death is imminent or I am permanently unconscious: [INSTRUCTIONS]

With respect to artificial nutrition and hydration, I direct the following:

[INITIALS] If my death is imminent or I am permanently unconscious, I do not want artificial nutrition and hydration. If it has been started, stop it.
[INITIALS] Even if my death is imminent or I am permanently unconscious, I want artificial nutrition and hydration.

Date: [DAY] day of [MONTH], 20[XX]    

_______________________________________
(your signature)

[ADDRESS, CITY, STATE, ZIP CODE]
(your address)

The declarant voluntarily signed this document in my presence.

Witness _________________________________

Address [ADDRESS, CITY, STATE, ZIP CODE]

Witness _________________________________

Address [ADDRESS, CITY, STATE, ZIP CODE]