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To My Family, Doctors and All Concerned With My Care: I,___________________________________ , being of sound mind, make this statement as a directive to be followed if I become unable to participate in decisions regarding my medical care. If I should be in an incurable or irreversible mental or physical condition with no reasonable expectation of recovery, I direct my attending physician to withhold or withdraw treatment that merely prolongs my dying. I further direct that the treatment be limited to measures intended to keep me comfortable or to relieve pain. These directions express my legal right to refuse treatment. Therefore,
I expect my family, doctors, and everyone concerned with my care to regard
themselves as legally and morally bound to act in accord with my wishes,
and in so doing to be free of any legal liability for having followed my
directions. I especially do not want (include specific treatments not wanted
such as cardiopulmonary resuscitation, respirator support, tube-feeding,
dialysis, surgery, blood transfusions, etc.)
_________________________________________________________________________ Other Instructions __________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Signature___________________________________________Date___________________ Address__________________________________________________________________ Phone______________________________ Witness____________________________________________Date___________________ Address_________________________________________Phone_____________________ Witness____________________________________________Date____________________ Address_________________________________________Phone_____________________ |