Notice: Any person eighteen years of age or older may execute a document which shall contain directions as to specific life support systems which such person chooses to have administered. Such document shall be signed and dated by the maker with at least two witnesses and may be in substantially the following form:

Document Concerning Withholding or Withdrawal of Life Support Systems

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 testament of my wishes.

I, _______________________ (Name), request that, if my condition is deemed terminal or if it is determined that I will 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 the environment. The life support systems which I do not want include, but are not limited to:

______ Artificial respiration
______ Cardiopulmonary resuscitation
______ Artificial means of providing nutrition and hydration
(Cross out and initial life support systems you want administered)

I do not intend any direct taking of my life, but only that my dying not be unreasonably prolonged.

Other specific requests:
_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

This request is made, after careful reflection, while I am of sound mind.

________________________ (Signature)
________________________ (Date)

This document was signed in our presence, by the above-named __________________ (Name) who appeared to be eighteen years of age or older, of sound mind and able to understand the nature and consequences of health care decisions at the time the document was signed.

_____________________ (Witness)

_______________________________ (Address)

_____________________ (Witness)

_______________________________ (Address)