DECLARATION
I ___________________________, being of sound mind, willfully and voluntarily make this declaration to be followed if I become incompetent. This declaration reflects my firm and settled commitment to refuse life-sustaining treatment under the circumstances indicated below. I direct my attending physician, and every other health care provider in whose treatment I may fall, to withhold, or withdraw, life-sustaining treatment that serves only to prolong the process of my dying, if I should be in a terminal condition or in a state of permanent unconsciousness. I direct treatment be limited to measures to keep me comfortable and to relieve pain, including any pain that might occur by withholding or withdrawing life sustaining treatment. If anyone does knowingly not follow this Declaration, that person shall be responsible for all costs and expenses associated with my medical care from that moment forward. In addition, if I an in the condition described above, I feel especially strongly about the following forms of treatment: I ( ) do ( ) do not want cardiac resuscitation. I ( ) do ( ) do not want mechanical respiration. I ( ) do ( ) do not want tube feeding or any other artificial or invasive form of nutrition (food) or hydration (water). I ( ) do ( ) do not want blood or blood products. I ( ) do ( ) do not want any form of surgery or invasive diagnostic tests. I ( ) do ( ) do not want kidney dialysis. I ( ) do ( ) do not want antibiotics. I realize that if I do not specifically indicate my preference regarding any of the forms of treatment listed above, I may receive that form of treatment. I ( ) do ( ) do not want to make an anatomical gift of all or part of my body, subject to the following limitations, if any:_________________________________________________ Other Instructions: I ( ) do ( ) do not want to designate another person as my surrogate to make medical treatment decisions for me if I should be incompetent and in a terminal condition or in a state of permanent unconsciousness. Name and address of surrogate ____________________________________ Name ____________________________________ Address ____________________________________ City, state and zip code (____)________________________________ Telephone number Name and address of substitute surrogate (if surrogate designated above is unable to serve): ____________________________________ Name ____________________________________ Address ____________________________________ City, state and zip code (____)______________________________ Telephone I made this declaration on the __________ day of __________________, 2002. ____________________________________ Declarant's signature ____________________________________ Address ____________________________________ City, state, zip code The declarant, or person on behalf of and at the direction of the declarant knowingly and voluntarily signed this writing by signature or mark in my presence.
____________________________________ Witness signature ____________________________________ Witness address ____________________________________ City, state and zip code	____________________________________ Witness signature ____________________________________ Witness address ____________________________________ City, state and zip code