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Statutory Short Form
This living will is effective only while I am unable to make or communicate my health care decisions.
(Some general statements concerning your health care options are outlined below. If you agree with one of the
statements, you should initial that statement. Read all of these statements carefully before you initial your
selection. You can also write your own statement concerning life-sustaining treatment and other matters relating
to your health care. You may initial any combination of paragraphs 1, 2, 3, and 4, but if you initial paragraph 5
the others should not be initialed.)

If I have a terminal condition I do not want my life to be prolonged and I do not want life-sustaining
treatment, beyond comfort care, that would serve only to artificially delay the moment of my death.


If I am in a terminal condition or an irreversible coma or a persistent vegetative state that my
doctors reasonably feel to be irreversible or incurable, I do want the m