HEALTH CARE ADVANCE DIRECTIVE


If I am incapable of making an informed decision regarding my health 
care, I direct my loved ones and health care providers to follow my 
instructions as set forth below. (Initial all those that apply.) 
 
For purposes of the provisions below, life-sustaining treatment means: 
the use of any medical device or procedure, artificially provided fluids, 
nutrition, drugs, surgery or therapy that use artificial means to sustain a 
vital bodily function to increase life span, which would serve only to 
artificially prolong my dying, 
 
(1) If I am diagnosed as having an incurable and irreversible illness, 
disease, or condition and if my attending physician and at least one 
additional physician who has personally examined me determine that 
my condition is terminal: 
 
_____ I direct that life-sustaining treatment be withheld or ended. I 
also direct that I be given all medically appropriate treatment and 
care necessary to make me comfortable and to relieve pain. 
 
_____ I direct that life-sustaining treatment be continued, if 
medically appropriate. 
 
(2) If there should come a time when I become permanently 
unconscious, and it is determined by my attending physician and at 
least one additional physician with appropriate expertise who has 
personally examined me, that I have totally and irreversibly lost 
consciousness and my ability to interact with other people and my 
surroundings: 
 
_____ I direct that life-sustaining treatment be withheld or 
discontinued. I understand that I will not experience pain or 
discomfort in this condition, and I direct that I be given all medically 
appropriate treatment and care necessary to provide for my personal 
hygiene and dignity. 
 
_____ I direct that life-sustaining treatment be continued, if 
medically appropriate. 
 
INSTRUCTIONS 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
(3) If there comes a time when I am diagnosed as having an incurable 
and irreversible illness, disease or condition which may not be 
terminal, but causes me to experience severe and worsening physical 
or mental deterioration, and I will never regain the ability to make 
decisions and express my wishes: 
 
_____ I direct that life-sustaining measures be withheld or 
discontinued and that I be given all medically appropriate care 
necessary to make me comfortable and to relieve pain. 
 
_____ I direct that life-sustaining treatment be continued, if medically 
appropriate. 
 
(4) If I am receiving life-sustaining treatment that is either (1) 
experimental and not a proven therapy, or (2) is likely to be ineffective 
or futile in prolonging life: 
 
_____ I direct that such life-sustaining treatment be withheld or 
withdrawn. I also direct that I be given all medically appropriate care 
necessary to make me comfortable and to relieve pain. 
 
_____ I direct that life-sustaining treatment be continued, if medically 
appropriate. 
 
 
(5) If I am in the condition(s) described above I feel especially strongly 
about the following forms of treatment: (initial all those that apply) 
 
______ I do not want cardiopulmonary resuscitation (CPR). 
______ I do not want mechanical respiration. 
______ I do not want tube feeding. 
______ I do not want antibiotics. 
______ I do want maximum pain relief, even if it may hasten my 
death. 
 
 
 
 
INCURABLE 
AND IRREVERSIBLE 
CONDITION THAT 
IS NOT TERMINAL 
 
 
 
 
 
 
 
 
 
 
 
 
 
EXPERIMENTAL 
AND/OR FUTILE 
TREATMENT 
 
 
 
 
 
 
 
 
 
 
 
SPECIFIC 
PROCEDURES 
AND/OR 
TREATMENT 
 
 
 
 
 
 
 
BRAIN DEATH: 
I may be declared legally dead when there has been an irreversible cessation of 
all functions of the entire brain, including the brain stem (also known as 
whole brain death).



 
ORGAN DONATION (OPTIONAL) 

I give my agent or the authority to make a gift of all or part of my
body after death for any legally authorized purpose.  


 
FURTHER INSTRUCTIONS: 
 
 
 
 
 
 
 
 
 
 
By writing this advance directive, I inform those who may become 
responsible for my health care of my wishes and intend to ease the 
burdens of decision making which this responsibility may impose. I have 
discussed the terms of this designation with my health care 
representative(s) and my representative(s) has/have willingly agreed to 
accept the responsibility for acting on my behalf in accordance with this 
directive and my wishes. I understand the purpose and effect of this 
document and sign it knowingly, voluntarily and after careful 
deliberation. 
 
Signed this ________ day of __________________________ 20______. 
 
 
Signature __________________________________________________ 
 
 
Address ____________________________________________________  
 
 
City __________________________________ State _______________ 
 
 
 
 
 
 
 
 
I declare that the person who signed this document or asked another to 
sign this document on his or her behalf, did so in my presence and he or 
she appears to be of sound mind and free of duress or undue influence. I 
am 18 years of age or older, and am not designated by this or any other 
document as the person’s health care representative or alternate health 
care representative. 
 
1. Witness ___________________________________________________ 
 
Address _____________________________________________________ 
 
City __________________________________ State _________________ 
 
Signature ________________________________ Date _______________ 
 
2. Witness ___________________________________________________ 
 
Address _____________________________________________________ 
 
City _________________________________ State __________________ 
 
Signature _________________________________ Date ______________