sound mind, willfully and voluntarily make this statement as directive to be followed if I am in a terminal condition and become unable to participate in decisions regarding my health care.  I understand that my health care providers are legally bound to act consistently with my wishes, within the limits of reasonable medical practice and other applicable law.  I also understand that I have the right to make medical and health care decisions for myself as long as I am able to do so and to revoke this living will at any time.

    (1) The

following are my feelings and wishes regarding my health care (you may state the circumstances under which this living will applies):  

_____________________________________________________________________ 

______________________________________________________________________ 

______________________________________________________________________ 

 

(2) I particularly want to

have all appropriate health care that will help in the following ways (you may give instructions for care you do want):  

_____________________________________________________________________ 

______________________________________________________________________ 

______________________________________________________________________ 

 

    (3) I particularly

do not want the following (you may list specific treatment you do not want in certain circumstances):  

_____________________________________________________________________ 

______________________________________________________________________ 

______________________________________________________________________ 

 

    (4) I particularly

want to have the following kinds of life-sustaining treatment if I am diagnosed to have a terminal condition (you may list the specific types of life-sustaining treatment that you do want if you have a terminal

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