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Do you wish to create a Living Will, Health Care Proxy or both?

Living Will

Health Care Proxy

Both (recommended)

Living Will

You will need to complete the health care questions below about your wishes regarding 1) artificial life support, 2) artificially administered food and water, and 3) comfort care if you are ever suffering from the following conditions:

• Terminal Condition:  A condition caused by injury, disease, or illness from which there is no reasonable medical probability of recovery and which, without treatment, can be expected to cause death.

• Permanent Coma:  A prolonged state of deep unconsciousness caused by disease, injury, poison, or other means and for which it has been determined that there exists no reasonable expectation of regaining consciousness.

• Persistent Vegetative State:  A permanent and irreversible condition in which a person makes no voluntary actions and demonstrates no evidence of having thoughts, is unable to communicate and is unaware of his or her own existence.

• Artificial life support:  Any medical procedure, treatment, or intervention which sustains, restores, or supplants a spontaneous vital bodily function.  For the purposes of this document, Artificial Life Support does not include procedures that are necessary to provide comfort or alleviate pain which would include pain-relief medicine, or artificially administered food or water.

• Artificially administered food or water:  Putting a tube into a person's stomach through the nose or a small hole in the abdomen to supply food and water.  This is also known as tube feeding.  This procedure is done for people who are too ill to chew or swallow by themselves or with someone else helping them.  Without a feeding tube, such a person will die within days or weeks depending upon their overall condition.

• Comfort care:  Treatment provided to the patient for the sole purpose of alleviating pan (includes pain-relief medication and/or prescription medication). Artificially administered food and water is not comfort care.  Comfort care may result in prolonging a person's life.

Terminal Condition

If my condition is determined to be terminal and with no hope of recovery, I would like the following done:

Life Support:  I DO NOT want to be kept alive by artificial life support. I want all possible life prolonging procedures.

Food and Water: I want to be given food and water. I DO NOT want to be given water to prolong my life.

Comfort Care:  I want to be provided comfort care. I DO NOT want to be provided comfort care to prolong my life.

Permanent Coma

If I am in a permanent coma with no hope of recovery, I would like the following done:

Life Support: I want all possible life prolonging procedures conducted. I DO NOT want to be kept alive by artificial life support.

Food and Water: I want to be given food and water. I DO NOT want to be given food and water.

Comfort Care: I want to be provided comfort care. I DO NOT want to be provided comfort care that may prolong my life.

Persistent Vegetative State

If I am in a persistent vegetative state with no hope of recovery, I would like that following done:

Life Support: I want all possible life prolonging procedures conducted. I DO NOT want to be kept alive by artificial life support.

Tube Feeding: I want food and water artificially administered. I DO NOT want food and water artificially administered.

Comfort Care: I want to be provided with comfort care. I DO NOT want to be provided comfort care that may prolong my life.

Additional instructions:

If there are any additional instructions concerning your medical care that you would like to express in detail, please note same in the box provided below. 

If you do not have any additional instructions, please note NONE in the box provided below in order to avoid any conflict that could arise.

Finish the following sentence: "I direct that"

Health Care Proxy

Your Health Care Proxy (also called Health Care Agent or Health Care Representative) will make health care decisions for you when you are no longer capable of making decisions for yourself, or if you are unable to communicate your decisions to others.  Your Health Care Proxy must be 18 years of age and should be someone whom you have instructed as to your wishes and should be a relative or close friend.

Health Care Proxy's Information

Full Name: 

Address: 

City:   State:   Zip Code:

Phone:  

Relationship: (e.g. spouse, sibling, friend, etc)

Would you like to name an Alternative Health Care Proxy (recommended)?

Yes  No

Alternative Proxy's Information

Full Name: 

Address:

City:   State:    Zip Code: 

Phone:

Relationship:  (e.g. spouse, sibling, friend, etc)