**********THIS DOCUMENT IS ONLY A SAMPLE**********

IT MAY NOT CONFORM TO THE LAWS IN YOUR STATE

 
I _____________________________ make this Health Care Treatment 
Directive to exercise my right to determine the course of my health 
care 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 prolonging procedure or 
other health care 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treatment proves to be ineffective, I direct treatment be withdrawn 
even if so doing may shorten my life.  
I direct I be given health care 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I direct all life prolonging procedures be withheld or withdrawn 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 which cannot be 
   significantly reversed.  
1.) When any of the above conditions exist, I DO NOT WANT the life 
prolonging procedures which 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 
2.) I make other instructions as follows: (You may describe what a 
minimally acceptable quality of life is for you.) 
___________________________________________________________________ 
___________________________________________________________________ 
___________________________________________________________________ 
___________________________________________________________________ 
If you do not wish to name an agent as referred to in the Durable 
Power of Attorney for Health Care Decisions, initial here________, 
write 'None' in the space provided for agent's name, sign and have 
witnessed and/or notarized.  
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.