WILLIAM DONALD SCHAEFER, Governor                            Ch. 372

FORM I

LIVING WILL

(OPTIONAL FORM)

IF I AM NOT ABLE TO MAKE AN INFORMED DECISION REGARDING MY HEALTH
CARE, I DIRECT MY HEALTH CARE PROVIDERS TO FOLLOW MY INSTRUCTIONS AS
SET FORTH BELOW. (INITIAL THOSE STATEMENTS YOU WISH TO BE INCLUDED IN
THE DOCUMENT AND CROSS THROUGH THOSE STATEMENTS WHICH DO NOT APPLY.)

A.       IF MY DEATH FROM A TERMINAL CONDITION IS IMMINENT AND EVEN IF
LIFE-SUSTAINING PROCEDURES ARE USED THERE IS NO REASONABLE
EXPECTATION OF MY RECOVERY -

I DIRECT THAT MY LIFE NOT BE EXTENDED BY LIFE-SUSTAINING
PROCEDURES, INCLUDING THE ADMINISTRATION OF NUTRITION AND HYDRATION
ARTIFICIALLY.

_______ I DIRECT THAT MY LIFE NOT BE EXTENDED BY LIFE-SUSTAINING

PROCEDURES, EXCEPT THAT, IF I AM UNABLE TO TAKE FOOD BY MOUTH, I WISH TO
RECEIVE NUTRITION AND HYDRATION ARTIFICIALLY.

I DIRECT THAT, EVEN IN A TERMINAL CONDITION, I BE GIVEN ALL
AVAILABLE MEDICAL TREATMENT IN ACCORDANCE WITH ACCEPTED HEALTH CARE
STANDARDS.

B.       IF I AM IN A PERSISTENT VEGETATIVE STATE, THAT IS IF I AM NOT
CONSCIOUS AND AM NOT AWARE OF MY ENVIRONMENT NOR ABLE TO INTERACT
WITH OTHERS, AND THERE IS NO REASONABLE EXPECTATION OF MY RECOVERY
WITHIN A MEDICALLY APPROPRIATE PERIOD -

I DIRECT THAT MY LIFE NOT BE EXTENDED BY LIFE-SUSTAINING
PROCEDURES, INCLUDING THE ADMINISTRATION OF NUTRITION AND HYDRATION
ARTIFICIALLY.

I DIRECT THAT MY LIFE NOT BE EXTENDED BY LIFE-SUSTAINING
PROCEDURES, EXCEPT THAT IF I AM UNABLE TO TAKE IN FOOD BY MOUTH, I WISH
TO RECEIVE NUTRITION AND HYDRATION ARTIFICIALLY.

I DIRECT THAT I BE GIVEN ALL AVAILABLE MEDICAL TREATMENT IN
ACCORDANCE WITH ACCEPTED HEALTH CARE STANDARDS.

C. IF I AM PREGNANT MY AGENT SHALL FOLLOW THESE SPECIFIC
INSTRUCTIONS:

BY SIGNING BELOW, I INDICATE THAT I AM EMOTIONALLY AND MENTALLY
COMPETENT TO MAKE THIS LIVING WILL AND THAT I UNDERSTAND ITS PURPOSE
AND EFFECT.

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