WILLIAM DONALD SCHAEFER, Governor                           S.B. 664

[ ] ₌₌₌ 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.

C. 3. IF I HAVE AN INEVITABLY FATAL END-STAGE CONDITION, THAT IS, A
CONDITION CAUSED BY INJURY, DISEASE, OR ILLNESS, AS A RESULT OF WHICH I
HAVE SUFFERED SEVERE DEBILITATION AND WILL LIKELY SUFFER FURTHER
IRREVERSIBLE DETERIORATION UNTIL A MEDICALLY FORESEEABLE DEATH
SEVERE AND PERMANENT DETERIORATION INDICATED BY INCOMPETENCY AND
COMPLETE PHYSICAL DEPENDENCY AND FOR WHICH, TO A REASONABLE DEGREE OF
MEDICAL CERTAINTY, TREATMENT OF THE IRREVERSIBLE CONDITION WOULD BE
MEDICALLY INEFFECTIVE -

[ ] ₌₌₌ 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.                                       

[ ] ₌₌₌ D. 4. I DIRECT THAT NO MATTER WHAT MY CONDITION, MEDICATION

NOT BE GIVEN TO ME AS NECESSARY TO RELIEVE PAIN AND SUFFERING, EVEN
THOUGH IT MAY IF IT WOULD SHORTEN MY REMAINING LIFE.

[ ] ₌₌₌ E. 5. I DIRECT THAT NO MATTER WHAT MY CONDITION, I BE GIVEN ALL
AVAILABLE MEDICAL TREATMENT IN ACCORDANCE WITH ACCEPTED HEALTH CARE
STANDARDS.

[ ] ₌₌₌ F. I DIRECT (IN THE FOLLOWING SPACE, INDICATE ANY OTHER

INSTRUCTIONS REGARDING RECEIPT OR NONRECEIPT OF ANY HEALTH CARE)

[ ] ₌₌₌  G. 6. IF I AM PREGNANT MY AGENT SHALL FOLLOW THESE SPECIFIC
INSTRUCTIONS 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.

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