Healthcare Treatment Directive

[This document is only a sample of a healthcare treatment directive. IT MAY NOT CONFORM TO THE LAWS IN YOUR STATE.]

I, _____________________________[your name], make this healthcare treatment directive to exercise my right to determine the course of my healthcare and to provide clear and convincing proof of my treatment decisions when I lack the capacity to make or communicate my decisions and there is no realistic hope that I will regain such capacity.

If my physician believes that a certain life-sustaining procedure or other healthcare treatment may provide me with comfort, relieve pain, or lead to a significant recovery, I direct my physician to try the treatment for a reasonable period of time. However, if such treatment proves to be ineffective, I direct treatment to be withdrawn even if so doing may shorten my life.

I direct that I be given healthcare treatment to relieve pain or to provide comfort even if such treatment might shorten my life, suppress my appetite or my breathing, or be habit forming.

I direct that all life-sustaining procedures be withheld or withdrawn when there is no hope of significant recovery, and I have:

• a terminal condition, or
• a condition, disease, or injury without reasonable expectation that I will regain an acceptable quality of life; or
• substantial brain damage or brain disease that cannot be significantly reversed.

1. When any of the above conditions exist, I DO NOT WANT the life prolonging procedures that I have initialed below. [You should assume any treatments not initialed may be administered to you.]
   • Surgery ________ [initials]
   • heart-lung resuscitation (CPR) ________ [initials]
   • antibiotics ________ [initials]
   • dialysis ________ [initials]
   • mechanical ventilator (respirator) ________ [initials]
   • tube feedings (food and water delivered through a tube in the vein, nose, or stomach) ________[initials]
   • other_________________________________________________________ [initials]

     ___________________________________________________ ________ [initials]

2. I make other instructions as follows: [You may describe here what a minimally acceptable quality of life is for you.]

   ________________________________________________________________________

   ________________________________________________________________________

   ________________________________________________________________________

   ________________________________________________________________________

3. Please see my Durable Power of Attorney for Healthcare for appointment of my agent for healthcare decisions at times when I am incapacitated for making my own healthcare decisions.

[Discuss this document and your ideas about quality of life with your agent, physician(s), family members, friends, and clergy and provide them with a signed copy (or photocopy thereof). You may revoke or change this document at any time. Periodic review is recommended. If there are no changes after each review, initial and date in the margin.]