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Sample Mple Samp Sa: Appendix B2

(1) This document is a living will declaring the signer's wish to forgo life-sustaining treatment if they lose substantial and irreversible mental capacity. (2) It specifies two triggering events that would initiate withdrawal of life-sustaining treatment - inability to eat/drink without assistance, or an incurable condition likely to cause death within a short time. (3) Upon a triggering event, no CPR or resuscitation would be administered and a DNR order placed in the medical record.

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10 views

Sample Mple Samp Sa: Appendix B2

(1) This document is a living will declaring the signer's wish to forgo life-sustaining treatment if they lose substantial and irreversible mental capacity. (2) It specifies two triggering events that would initiate withdrawal of life-sustaining treatment - inability to eat/drink without assistance, or an incurable condition likely to cause death within a short time. (3) Upon a triggering event, no CPR or resuscitation would be administered and a DNR order placed in the medical record.

Uploaded by

DEShif
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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APPENDIX B2

Living Will

e
l
p

TO MY FAMILY, all physicians, hospitals and other health


heal care
providers and any court or judge:
I, _______________, of __________________________________
______________________
_______________________________

m
a

declare that after thoughtful


onsideration, I have decided that I wish tto
houghtful consideration,
forgo all life-sustaining
ng treatment if I shall in the future sustain
fe-sustaining
su
substantial
versible loss of mental capacity AND
ntial and irreversible

and tube(s), or other


assist
(a) I am unable to eat or drink without assistance
assistanc
artificial means are required to feed me and it is highly unlikely that
I will ever be able to ea
eat and drink without artificial feeding.
OR

(b) I have an iincurable or irreversible condition that is likely to cause


my ddeath within a relatively short time.
Such loss of mental capacity by me as described above is sometimes
referred to herein as a triggering event. All life-sustaining treatment
ent shall
s
be withheld or withdrawn from me upon the occurrence of a triggeri
triggering
event whether or not I am conscious, alert or free from
rom pain. The term
life-sustaining treatment is intended to include,
clude, without limitation,
nutrition and hydration of any kind, artificial
wise whenever that
ificial or otherwise
term is used in this instrument.

e
l
p
m
a

As used herein, the term an incurable


urable or irreversible condition
conditi that is
likely to cause my death within a relatively short time
tim shall mean a
condition that would, without
procedures
ithout the administration of medical
m
pr
thatt serve only to prolong the process of dying, resul
result in my
m death within
a relatively short time.

res
No cardiopulmonary resuscitation
sshall be administered to me if I
arrest
following the occurrence of a
stain cardiac or pulmonary
pu
sustain
a
triggering
iggering event.
eve Effective upon the occurrence of a triggering event, I
riggering
consent
sent to an order nnot to resuscitate as that term is defined in 2961 of
nsent
the Public Hea
Health /DZRIWKH6WDWHRI1HZ<RUN '15RUGHU DQGGLUHFW
that a DNR
order be placed in my medical record maintained by each
D
physician, hospital and other health care provider furnishing medical care
to me.

I recognize that when life-sustaining treatment is withheld or withdrawn


from me, I will surely die of dehydration and malnutrition within days or
weeks. I direct that all available medication for the relief of pai
pain and for
my comfort shall be administered to me after life-sustaining
treatment is
ustaining trea
withheld or withdrawn even if I am rendered unconscious
nconscious and my life is
shortened thereby.

e
l
p

Notwithstanding the above,


ng will shall be suspended if I am
ve, this living
pregnant.

m
a

I have executed this


is instrument while in full command
com
of my faculties
in order to furnish clear and convincing proof of

determination to forgo life-sustaining


the strength and durability of my determinat
referred to herein;
c
treatment in any of the circumstances
conviction that I am entitled to forgo such treatment
se
my firm and settled
convic
in the exercise of my constitutional and common-law rights to
the course of medical treatment; and
dete
determine
my belief that my right to forgo such treatment is paramount to any
m
responsibility of any health care provider or the authority of any court
or judge to attempt to force unwanted medical care upon me.

e
l
p

I direct that my family, all physicians, hospitals and


care
d other health ca
nd
car
providers and any court or judge honor my decision
n not to artificially
extend my life by mechanical means, and if there iss any doubt as to
whether or not life-sustaining treatment
ment is to bee administered to me after
I have sustained substantial and irreversiblee loss of mental capacity, such
doubt is to be resolved
withdraw
ed in favor of withholding or withdrawing
such
treatment. Thesee directionss express my legal right to refuse
treatment. I
re
treatment
intend myy instructions to
o be carried out, unless I have rescinded them in
a new
chang my
ew writing or by clear indication that I have changed
m mind.

m
a

20_
DATED: _______________, 20__
__________________________
_________
_________________________
ame
Name

Witness:_____________________
tness:_______

Address:_____________________

Witness:_____________________

Address:_____________________

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