1. If my doctor determines that my death is imminent (very close) and medical treatment will not help me recover, then: I do not want any treatments to prolong my life. This includes tube □ ____ feeding, IV fluids, cardiopulmonary resuscitation (CPR), ventilator/respirator (breathing machine), kidney dialysis or antibiotics. I understand that I still will receive treatment to relieve pain and make me comfortable. want all treatments to prolong my life as long as possible within the ____I □ limits of generally accepted health care standards. I understand that I will receive treatment to relieve pain and make me comfortable. ____ Other choices, as follows: □ 2. If my condition makes me unaware of myself or my surroundings or unable to interact with others, and it is reasonably certain that I will never recover this awareness or ability even with medical treatment, then: I do not want any treatments to prolong my life. This includes tube ____ □ feeding, IV fluids, cardiopulmonary resuscitation (CPR), ventilator/respirator (breathing machine), kidney dialysis or antibiotics. I understand that I still will receive treatment to relieve pain and make me comfortable. I want all treatments to prolong my life as long as possible within the ____ □ limits of generally accepted health care standards. I understand that I will receive treatment to relieve pain and make me comfortable. I want to try treatments for a period of time in the hope of some ____ □ improvement of my condition. I suggest ________________________________ as the period of time after which such treatment should be stopped if my condition has not improved. Any agent or surrogate may specify the exact time period in consultation with my physician. I understand that I still will receive treatment to relieve pain and make me comfortable. ____ Other choices, as follows: □
1. If my doctor determines that my death is imminent (very close) and medical treatment will not help me recover, then: □ ____ I do not want any treatments to prolong my life. This includes tube feeding, IV fluids, cardiopulmonary resuscitation (CPR), ventilator/respirator (breathing machine), kidney dialysis or antibiotics. I understand that I still will receive treatment to relieve pain and make me comfortable. □ ____I want all treatments to prolong my life as long as possible within the limits of generally accepted health care standards. I understand that I will receive treatment to relieve pain and make me comfortable. □ ____ Other choices, as follows: 2. If my condition makes me unaware of myself or my surroundings or unable to interact with others, and it is reasonably certain that I will never recover this awareness or ability even with medical treatment, then: □ ____ I do not want any treatments to prolong my life. This includes tube feeding, IV fluids, cardiopulmonary resuscitation (CPR), ventilator/respirator (breathing machine), kidney dialysis or antibiotics. I understand that I still will receive treatment to relieve pain and make me comfortable. □ ____ I want all treatments to prolong my life as long as possible within the limits of generally accepted health care standards. I understand that I will receive treatment to relieve pain and make me comfortable. □ ____ I want to try treatments for a period of time in the hope of some improvement of my condition. I suggest ________________________________ as the period of time after which such treatment should be stopped if my condition has not improved. Any agent or surrogate may specify the exact time period in consultation with my physician. I understand that I still will receive treatment to relieve pain and make me comfortable. □ ____ Other choices, as follows: