1. Print Name: _____________________________________________________________ Birth Date: ____________________
Address: ______________________________________________________ Social Security #: ___________________________
2. I, ______________________________________________ , being of sound mind, make this statement as instructions to be followed if I become permanently unable to participate in decisions regarding my medical care. These instructions reflect my firm decision to decline medical treatment under the following circumstances indicated below.
3. If I have an incurable or irreversible condition that renders me incapable of making decisions on my own and there is no reasonable expectation that I will recover, then I direct my attending physician to withhold or withdraw treatment that only prolongs my dying.
These instructions only apply if: (Check those statements you agree with:)
q I am in a terminal condition
q I am minimally conscious with irreversible brain damage
q I have Alzheimer's or another form of dementia
q I am permanently unconscious
q Other ___________________________________________________
I instruct that my treatment be limited to measures to keep me comfortable and to relieve pain.
While I understand that I am not legally required to be specific about future treatments, if I am in the conditions) described above I have strong beliefs about the following forms of treatment: (Check those statements that you agree with:)
q I do not want cardiopulmonary resuscitation (CPR).
qI do not want mechanical ventilation (respirator).
q I do not want artificial nutrition and hydration (intravenous fluids or feeding tube).
qI do not want medical treatment (antibiotics/other medications) unless they are necessary for my comfort.
q I do not want hospitalization.
4. Other directions/instructions that you wish to add (for additional space, use the bottom or back of this form):
5. These express my legal right to refuse treatment, under the law in New York. I intend my instructions to be carried out unless I have changed them in writing or by clearly indicating that I have changed my mind.
Signed: _________________________________________ Today's Date: __________________
(Sign and Date this document)