WILLIAM DONALD SCHAEFER, Governor                           S.B. 664

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 I AM IN MY DEATH FROM A TERMINAL CONDITION IS IMMINENT; AND;
DESPITE THE APPLICATION OF EVEN IF LIFE-SUSTAINING PROCEDURES; ARE USED
THERE IS NO REASONABLE REASONABLE EXPECTATION OF MY RECOVERY -

[ ]              I DIRECT THAT MY LIFE NOT BE EXTENDED BY LIFE PROLONGING

LIFE-SUSTAINING PROCEDURES, INCLUDING THE ARTIFICIAL ADMINISTRATION OF
NUTRITION AND HYDRATION ARTIFICIALLY THROUGH TUBES.

[ ]            I DIRECT THAT MY LIFE NOT BE EXTENDED BY LIFE PROLONGING

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

[ ]           I DIRECT THAT. EVEN IN A TERMINAL CONDITION, 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 REASONABLE EXPECTATION OF MY
RECOVERY WITHIN A MEDICALLY APPROPRIATE PERIOD -

[ ]              I DIRECT THAT MY LIFE NOT BE EXTENDED BY LIFE PROLONGING

LIFE-SUSTAINING PROCEDURES, INCLUDING THE ARTIFICIAL ADMINISTRATION OF
NUTRITION AND HYDRATION ARTIFICIALLY THROUGH TUBES.

[ ]              I DIRECT THAT MY LIFE NOT BE EXTENDED BY LIFE PROLONGING

LIFE-SUSTAINING PROCEDURES, EXCEPT THAT IF I AM UNABLE TO TAKE IN FOOD
BY MOUTH, I WISH TO RECEIVE NUTRITION AND HYDRATION THROUGH TUBES
ARTIFICIALLY.

[ ]______I DIRECT THAT, EVEN IN A PERSISTENT VEGETATIVE STATE; 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:

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