I,   being of sound mind, make this statement as a directive to be followed if I become permanently unable to participate in decisions regarding my medical care. These instructions reflect my firm and settled commitment to decline medical treatment under the circumstances indicated below.

I direct my attending physician to withhold or withdraw treatment that serves only to prolong the process of my dying, if I should be in an incurable or irreversible mental or physical condition with no reasonable expectation of recovery.

These instructions apply if I am (a) in a terminal condition; (b) permanently unconscious; or (c) if I am conscious but have irreversible brain damage and will never regain the ability to make decisions and express my wishes.

I direct that treatment be limited to measures to keep me comfortable and to relieve pain, including any pain that might occur by withholding or withdrawing treatment.

While I understand that I am not legally required to be specific about future treatments, if I am in the condition(s) described above I feel especially strongly about the following forms of treatment: (initial those directives you wish to invoke).

Initial the items that apply to your wishes:

I do not want cardiac resuscitation
I do not want antibiotics.
I do not want mechanical respiration.
I do not want tube feeding.
I do want maximum pain relief.
I direct that no blood transfusions (whole blood, red cells, white cells, platelets, or blood plasma) be given to me under any circumstances. I will accept nonblood volume expanders (such as dextran, saline or Ringer's solution, or hetastarch) and other non-blood management.

Other directions: (indicate none if none apply)

These directions express my legal right to refuse treatment, under the law of the State of Any State. I intend my instructions to be carried out, unless I have rescinded them in a new writing or by clearly indicating that I have changed my mind.

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Signature of party to this directive

Date:        

Witness:

Address:

Witness:

Address: