At your Own Risk
(Directive to Physicians)
Directive made this ____ day of ___________, 20____.
I, _______________________, being of sound mind, willfully, and
voluntarily make known my desire that my life shall not be artificially
prolonged under the circumstances set forth below, do hereby declare:
GENERAL PRESUMPTION FOR LIFE
I direct my health care provider(s) and health care agent to make
health care decisions consistent with my general desire for the
use of medical treatment that would preserve my life, as well as
for the use of medical treatment that can cure, improve, or reduce
or prevent deterioration in, any physical or mental condition.
Food and water are not medical treatment, but basic necessities.
I direct my health care provider(s) and health care agent to provide
me with food and fluids orally, intravenously, by tube, or by other
means to the full extent necessary both to preserve my life and
to assure me the optimal health possible.
I direct that medication to alleviate my pain be provided, as long
as the medication is not used in order to cause my death.
I direct that the following be provided: the administration of
medication, cardiopulmonary resuscitation (CPR), and the performance
of all other medical procedures, techniques, and technologies. including
surgery, - all to the full extent necessary to correct, reverse,
or alleviate life-threatening or health-impairing conditions, or
complications arising from those conditions.
I also direct that I be provided basic nursing care and procedures
to provide comfort care.
I reject, however, any treatments that use an unborn or newborn
child, or any tissue or organ of an unborn or newborn child, who
has been subject to an induced abortion. This rejection does not
apply to the use of tissues or organs obtained in the course of
the removal of an ectopic pregnancy.
I also reject any treatments that use an organ or tissue of another
person obtained in a manner that causes, contributes to, or hastens
that person's death.
The instructions in this document are intended to be followed even
if suicide is alleged to be attempted at some point after it is
I request and direct that medical treatment and care be provided
to me to preserve my life without discrimination based on my age
or physical or mental disability or the "quality" of my
life. I reject any action or omission that is intended to cause
or hasten my death.
I direct my health care provider(s) and health care agent to follow
the above policy, even if I am judged to be incompetent.
During the time I am incompetent, my agent, as named below, is
authorized to make medical decisions on my behalf, consistent with
the above policy, after consultation with my health care provider(s),
utilizing the most current diagnoses and/or prognosis of my medical
condition, in the following situations with the written special
WHEN MY DEATH IS IMMINENT
A. If I have an incurable terminal illness or injury, and I will
die imminently - meaning that a reasonably prudent physician, knowledgeable
about the case and the treatment possibilities with respect to the
medical conditions involved, would judge that I will live only a
week or less even if lifesaving treatment or care is provided to
me - the following may be withheld or withdrawn:
- Any treatment that will, itself, cause me severe, intractable,
and long-lasting pain but will not cure me.
WHEN I AM TERMINALLY ILL
B. Final Stage of Terminal Condition. If I have an incurable terminal
illness or injury and even though death is not imminent I am in
the final stage of that terminal condition - meaning that a reasonably
prudent physician, knowledgeable about the case and the treatment
possibilities with respect to the medical conditions involved, would
judge that I will live only three months or less, even if lifesaving
treatment or care is provided to me - the following may be withheld
- Medications intended to relieve pain but which seriously threaten
to shorten my life.
C. OTHER SPECIAL CONDITIONS:
IF I AM PREGNANT
D. Special Instructions for Pregnancy. If I am pregnant, I direct
my health care provider(s) and health care agent to use all lifesaving
procedures for myself with none of the above special conditions
applying if there is a chance that prolonging my life might allow
my child to be born alive. I also direct that lifesaving procedures
be used even if I am legally determined to be brain dead if there
is a chance that doing so might allow my child to be born alive.
Except as I specify by writing my signature in the box below, no
one is authorized to consent to any procedure for me that would
result in the death of my unborn child.
If I am pregnant, and I am not in the final stage of a terminal
condition as defined above. medical procedures required to prevent
my death are authorized even if they may result in the death of
my unborn child provided every possible effort is made to preserve
both my life and the life of my unborn child.
This directive shall have no force or effect five years from the
date filled in above.
I understand the full import of this directive and I am emotionally
and mentally competent to make this directive in the City of ___________,
County of _________, State of ________________.
The declarant has been personally known to me and I believe his/her
to be of sound mind. I did not sign the declarant's signature above
for or at the direction of the declarant. I am at least 18 years
of age and am not related to the declarant by blood or marriage,
nor entitled to any portion of the estate of the declarant according
to the laws of intestate succession of the State of California or
under any will of the declarant or codicil thereto as of the date
of declarant's signature. Neither am I directly financially responsible
for declarant's medical care. I am not the declarant's attending
physician, an employee of the attending physician, or an employee
of the health or care facility in which the declarant is a patient.
Witness (sign) _______________________________________________
Witness (sign) _______________________________________________
Subscribed and acknowledged, before me by___________________ __________________________,
and subscribed and sworn to before the witnesses, on the _______day
of ____________________, 20___.
State of ___________________
My Commission Expires: ____________________________
Copies of this instrument have been given to:
Receipt and acknowledged & date: