"___ Artificial nutrition and hydration must be administered even when other interventions are withheld or withdrawn. OR
"___ Artificial nutrition and hydration should be administered according to the same guidelines as other life-sustaining interventions.
"-- If my doctor and one other physician reasonably determine that my death is likely to occur within two weeks and life support will only prolong my death:
"(initial one)
"___ I want life support measures to continue. OR
"___ I want life support stopped or if it has not started, I do not wish for it to start. OR
"___ I want life support if my doctor thinks it will help, but I do not want life support if it does not improve my condition or help my symptoms.
"-- If my physician and one other qualified physician familiar with my case decide that I am permanently and severely brain damaged (meaning I cannot speak, and cannot respond to my environment) and they do not expect my condition to improve and life support would only delay my death:
"(initial one)
"___ I want life support measures to continue. OR
"___ I want life support stopped or if it has not started, I do not wish for it to start. OR
"___ I want life support if my doctor thinks it will help, but I do not want life support if it does not improve my condition or help my symptoms.
"-- If my doctor and one other qualified physician familiar with my case decide that I am in a coma, or that I am brain damaged and they do not expect me to wake up or recover and they do not expect my condition to improve, and life support would only delay my death:
"(initial one)
"___ I want life support measures to continue. OR
"___ I want life support stopped or if it has not started, I do not wish for it to start. OR
"___ I want life support if my doctor thinks it will help, but I do not want life support if it does not improve my condition or help my symptoms."
The form then provides a section in which a person may specify "other conditions in which I do not want to have life support."
© 2005 Baptist Press. Used with permission. All rights reserved.
