LIVING WILL or HEALTH CARE INSTRUCTIONS
If the time comes when I am incapacitated to the point when I can no longer actively take part in
decisions for my own life, and am unable to direct my physician as to my own medical care, I
wish this statement to stand as a statement of my wishes.
I, ________________________________, the author of this document, request that, if my
condition is deemed terminal or if I am determined to be permanently unconscious, I be
allowed to die and not be kept alive through life support systems.
By terminal condition, I mean that I have an incurable or irreversible medical condition which,
without the administration of life support systems, will, in the opinion of my attending physician,
result in death within a relatively short time. By permanently unconscious I mean that I am in a
permanent coma or persistent vegetative state which is an irreversible condition in which I am at
no time aware of myself or the environment and show no behavioral response to th