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HEALTH CARE DIRECTIVE Living Will)
HEALTH CARE DIRECTIVE (Living Will)
HEALTH CARE DIRECTIVE (Living Will)
Directive made this day of _____________ I________________, ___________, a resident of the City of ¬¬¬¬¬¬¬¬¬¬¬¬¬¬_____________ in the County of______________, State of New York having the capacity to make my own health care decision, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below and do hereby declare that:
a. If at any time I should be diagnosed in writing by my attending physician to be in a terminal condition, or by two physicians to be in a permanent unconscious condition, and if the application of life-sustaining treatment would serve only to prolong artificially the process of my dying, I direct that such treatment be withheld or withdrawn and that I be permitted to die naturally.
I understand by using this form that a terminal condition means an incurable and irreversible condition caused by injury, disease, or illness which would within reasonable medical judgment cause death within a reasonable period of time in accordance with accepted medical standards, and when the application of life-sustaining treatment would serve only to prolong the process of dying. I further understand that a permanent unconscious condition means an incurable and irreversible condition in which I am assessed within reasonable medical judgment as having no reasonable probability of recovery from an irreversible coma or a persistent vegetative state.
b. In the absence of my ability to give directions regarding the use of such life sustaining treatment, it is my intention that this Directive shall be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment, and I accept the consequences of such refusal. If another person is appointed to make these decisions for me, whether through a Durable Power of Attorney for Health Care or otherwise, I request that the person be guided by this Directive and any other clear expressions of my desires.
c. If I am diagnosed to be in a terminal condition or in a permanent unconscious
condition (initial & date selection):_______________
I do want to have artificially provided nutrition. (initial)______ (date)_______________
I do not want to have artificially provided nutrition. (initial)_______ (date)______________
d. If I am diagnosed to be in a terminal condition or in a permanent unconscious
condition (initial & date selection):
I do want to have artificially provided hydration. (initial)____ (date)_____________
I do not want to have artificially provided hydration. (initial) ____(date)______________
e. If I have been diagnosed as pregnant and that diagnosis is known to my physician, this Directive shall have no force or effect during the course of my pregnancy.
f. I understand the full import of this Directive, and I am emotionally and mentally capable to make the health care decisions contained in this Directive.
g. I understand that before I sign this Directive, I can add to or delete from or otherwise change the wording of this Directive, that I may destroy, revoke or alter this Directive at any time, and that any changes shall be consistent with New York State law or federal constitutional law to be legally valid.
h. It is my wish that every part of this Directive be fully implemented. If for any reason any part is held invalid, it is my wish that the remainder of my Directive be implemented.
I make the following additional directions regarding my care:
Signature:_____________________Print Name:______________________
Address:__________________________
SS NUMBER :________________________
COUNTY OF:____________________________
Signed Date___________________________________
MUST BE NOTARIZED