The Christian Medical Association form, meanwhile, states under a section titled, "My Medical Treatment":

"I believe that life is very precious, a gift from God. I deserve to be treated with dignity and respect. If I cannot speak or decide for myself, I want the following requests carried out:

"-- All procedures directed by my physician should provide me with as much comfort and respect as possible.

"-- I want to be fed and hydrated by mouth if possible.

"-- I want to be kept warm and clean at all times.

"-- I do not want to be in pain. My doctor should give me medication to control my pain, regardless of whether that makes me drowsy or whether I sleep more than normal.

"-- If one or more physicians who have personally examined me reasonably believe that I am likely to die within 2 weeks as a result of a disease or illness despite receiving all appropriate medical treatment, then I want all burdensome procedures that would prolong the dying process to be withheld or withdrawn.

"-- I forbid any form of physician-assisted suicide, euthanasia or any other action done with the intent of ending my life.

"-- I want to be given food and fluids as long as I can swallow. If I am unable to swallow:

"(initial one)

"___ Artificial nutrition and hydration must be administered even when other interventions are withheld or withdrawn.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."

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