WILLIAM DONALD SCHAEFER, Governor                            Ch. 372

(3) IF I HAVE AN END-STAGE CONDITION, THAT IS A CONDITION CAUSED BY
INJURY, DISEASE, OR ILLNESS, AS A RESULT OF WHICH I HAVE SUFFERED SEVERE
AND PERMANENT DETERIORATION INDICATED BY INCOMPETENCY AND COMPLETE
PHYSICAL DEPENDENCY AND FOR WHICH, TO A REASONABLE DEGREE OF MEDICAL
PROBABILITY CERTAINTY, TREATMENT OF THE IRREVERSIBLE CONDITION WOULD
BE MEDICALLY INEFFECTIVE -

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.

_______ (4) I DIRECT THAT NO MATTER WHAT MY CONDITION, MEDICATION NOT

BE GIVEN TO ME TO RELIEVE PAIN AND SUFFERING, IF IT WOULD SHORTEN MY
REMAINING LIFE.

______ (5) I DIRECT THAT NO MATTER WHAT MY CONDITION, I BE GIVEN ALL

AVAILABLE MEDICAL TREATMENT IN ACCORDANCE WITH ACCEPTED HEALTH CARE
STANDARDS.

(6) IF I AM PREGNANT, MY DECISION CONCERNING LIFE-SUSTAINING PROCEDURES
SHALL BE MODIFIED AS FOLLOWS:

(7) I DIRECT (IN THE FOLLOWING SPACE, INDICATE ANY OTHER INSTRUCTIONS
REGARDING RECEIPT OR NONRECEIPT OF ANY HEALTH CARE)

BY SIGNING BELOW, I INDICATE THAT I AM EMOTIONALLY AND MENTALLY
COMPETENT TO MAKE THIS ADVANCE DIRECTIVE AND THAT I UNDERSTAND THE
PURPOSE AND EFFECT OF THIS DOCUMENT.

____________(DATE)_____________________________________(SIGNATURE OF DECLARANT)

THE DECLARANT SIGNED OR ACKNOWLEDGED SIGNING THE FOREGOING
ADVANCE DIRECTIVE IN MY PRESENCE AND BASED UPON PERSONAL OBSERVATION
APPEARS TO BE A COMPETENT INDIVIDUAL.

(WITNESS)______________________________________________(WITNESS)

(SIGNATURE OF TWO WITNESSES)

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