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I, __________________________, being
of sound mind, willfully and voluntarily provide as follows:
A. LIVING WILL DECLARATION
I 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 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 that 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.
In addition, if I am in the condition
described above, I direct that the forms of treatment marked below be
withheld or withdrawn:
_____ cardiac resuscitation
_____ mechanical respiration
_____ tube feeding or any other
artificial or invasive form of nutrition (food) or hydration (water)
_____ blood or blood products
_____ any form of surgery or invasive
diagnostic tests
_____ kidney dialysis
_____ antibiotics
I realize that if I do not
specifically indicate my preference regarding the withdrawal or withholding
of any of the forms of treatment listed above, I may receive that form of
treatment.
B. HEALTH CARE SURROGATE AND AGENT DESIGNATION
I hereby designate
_____________________________ whose address is
____________________________________________________________:
1. As my surrogate to make medical
decisions for me if I should be incompetent and either in a terminal
condition or in a state of permanent unconsciousness.
2. As my agent to do the following:
(a) To authorize my admission to a medical, nursing, residential or similar
facility and to enter into agreements for my care.
(b) To authorize medical and surgical procedures.
(c) To authorize an anatomical gift of all or any part of my body.
(d) To request and receive from any health care provider all of my
individually identifiable health information and medical records relating to
my physical and mental condition and to my diagnosis, prognosis, care and
treatment. This authority given by me to my agent shall be considered a
consent to the release of such information under all applicable laws and
shall include (but not be limited to) the express grant of authority to
personal representatives as provided by Regulation Section 164.502(g) of
Title 45 of the Code of Federal Regulations and the medical information
privacy law and regulations generally referred to as HIPAA (or any successor
thereto). This authority given to my agent has no expiration date and shall
expire only in the event that I revoke the authority in a writing delivered
to my health care provider. The term "health care provider" shall include
(but not be limited to) any physician, health care professional, dentist,
health plan, hospital, clinic, laboratory, pharmacy or other covered health
care provider, any insurance company and the Medical Information Bureau,
Inc. or other health care clearinghouse that has provided treatment or
services to me, or that has paid for or is seeking payment from me for such
services. Each reference to applicable laws shall include all laws now or in
the future, any rules and regulations promulgated thereunder from time to
time (and any amendments thereto).
This document shall not be affected
by my subsequent disability or incapacity, or lapse of time.
Executed this __________ day of
______________, 2005.
________________________________
Declarant
The declarant, knowingly and
voluntarily signed this writing in our presence.
_____________________________
_______________________________
Witness's signature Witness's address
_____________________________
_______________________________
Witness's signature Witness's address
SOURCE:
PHL:5109866.1/1-102005 "Here's
My Living Will - And Yours
(4/7/2005)"
(http://www.mastalk.com/mastalk/dailynews.jspx)
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