6 . Statement of Desires Concerning Treatment
With respect to decisions to withhold or withdraw life-sustaining treatment , your Attorney-In-Fact must make healthcare decisions that are consistent with your known desires . You can , but are not required to , indicate your desires below . If your desires are unknown , your Attorney-In-Fact has the duty to act in your best interests ; and , under some circumstances , a judicial proceeding may be necessary so a court can determine the healthcare decision that is in your best interests . If you wish to indicate your desires , you may INITIAL the statement or statements that reflect your desires and / or write your own statements in the space below .
If the statement reflects your desires , initial the box next to the statement .
1 . I desire that my life be prolonged to the greatest extent possible , without regard to my condition , the chances I have for recovery or long-term survival , or the cost of the procedures .
2 . If I am in a coma which my doctors or advanced practice registered nurses have reasonably concluded is irreversible , I desire that life-sustaining or prolonging treatments not be used .
3 . If I have an incurable or terminal condition or illness and no reasonable hope of long-term recovery or survival , I desire that life-sustaining or prolonged treatments not be used .
4 . Withholding or withdrawal of artificial nutrition and hydration may result in death by starvation or dehydration . I want to receive or continue receiving artificial nutrition and hydration by way of the gastrointestinal tract after all other treatment is withheld .
5 . I do not desire treatment to be provided and / or continued if the burdens of the treatment outweigh the expected benefits . My Attorney-In-Fact is to consider the relief of the suffering , the preservation or restoration of functioning , and the quality as well as the extent of the possible extension of my life .
6 . If I have an incurable or terminal condition , including late stage dementia , or illness and no reasonable hope of long-term recovery or survival , I desire my attending physician to administer any medication to alleviate suffering without regard that the medication is likely to cause addiction or reduce the extension of my life .
If you wish to change your answer , you may do so by drawing an “ X ” through the answer you do not want and circling the answer you prefer .
Other or additional statements of desires : _____________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________
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