DIRECTED TO MY FAMILY, MY PHYSICIAN, MY LAWYER
AND ALL OTHERS WHOM IT MAY CONCERN
As is love, as is growth, so too is death a part of life. As I have experienced love, growth, my family and my friends, I have been able to make decisions about the conduct of my life. So too I wish to make decisions about the conduct of my death. If the time comes when I can no longer take part in decisions for my own future, let this statement stand as an expression of my wishes and directions, while I am still of sound mind.
If at such a time a situation should arise in which there is no reasonable expectation of my recovery from extreme physical or mental disability, I direct that I be allowed to die and not be kept alive by medications, artificial means or “heroic measures.” I do ask, however, that medication be mercifully administered to me to alleviate suffering, even though this may shorten my remaining life.
This statement is made after careful consideration and is in accordance with my strong convictions and beliefs. I have thought carefully about the manner in which I wish to die and I have discussed it fully with my family.
If I should be in a terminal condition or in a state of permanent unconsciousness, I feel especially strong about the following forms of treatment:
I ( ) do ( ) do not want cardiac resuscitation.
I ( ) do ( ) do not want mechanical respiration.
I ( ) do ( ) do not want tube feedings.
I ( ) do ( ) do not want other artificial or invasive forms of nutrition. (food)
I ( ) do ( ) do not want other artificial or invasive forms of hydration. (water)
I ( ) do ( ) do not want blood or blood products.
I ( ) do ( ) do not want any form of surgery.
I ( ) do ( ) do not want any invasive diagnostic tests.
I ( ) do ( ) do not want kidney dialysis.
I ( ) do ( ) do not want antibiotics.
I ( ) do ( ) do not _____________________________________.
This list is not meant to be comprehensive or exclusive; it is merely meant to be illustrative and to operate as a guide to my family, physician, and lawyer.