Living will

Your Name

First Middle Last

Terminal Condition

A "Terminal Condition" is an incurable or irreversible condition for which the administration of life-sustaining procedures will serve only to postpone the moment of your death.

If two doctors certify in writing that you have a terminal condition and you are not able to effectively receive or evaluate information or communicate decisions, please choose one of the following:

Life-sustaining procedures are to be withdrawn and/or withheld.
Life-sustaining procedures shall be continued for a specified period of time.
I direct that life-sustaining procedures shall be continued indefinitely.

"Life Sustaining Procedures" include any medical procedure or intervention that, if administered to a qualified patient, would serve only to prolong the dying process. It does not include any medical procedure or intervention for nutrition or hydration of the qualified patient or considered necessary by the attending physician or advanced practice nurse to provide comfort or alleviate pain.

How long do you want to have life-sustaining procedures continued? (Days, Weeks, Months)

Do you wish to continue artificial nutrition or hydration if you have been diagnosed with a terminal condition?

Yes, indefinitely
Yes, for a specified period of time
No

How long do you want to have artificial nutrition or hydration continued? (Days, Weeks, Months)

Persistent Vegetative State (CO) / Permanent Unconscious Condition (WA)

“Persistent Vegetative State” (Colorado) is not specifically defined, but rather is decided by reference to the criteria and definitions employed by the prevailing medical community standards of practice. It generally includes a medical state in which, within a reasonable degree of medical probability, the patient can no longer think, feel anything, knowingly move, or be aware of being alive. The physicians must agree this condition will last indefinitely without hope for improvement and they must have monitored the patient long enough to make that decision. "Permanent Unconscious Condition" (Washington ) is an incurable and irreversible condition in which you are medically assessed within reasonable medical judgment as having no reasonable probability of recovery from an irreversible coma or a persistent vegetative state.

If two doctors certify in writing that you are in a persistent vegetative state and you are not able to effectively receive or evaluate information or communicate decisions, please choose one of the following:

Life-sustaining procedures are to be withdrawn and/or withheld.
Life-sustaining procedures shall be continued for a specified period of time.
I direct that life-sustaining procedures shall be continued indefinitely.

How long do you want to have life-sustaining procedures continued? (Days, Weeks, Months)

Do you wish to continue artificial nutrition or hydration if you have been diagnosed to be in a persistent vegetative state?

Yes, indefinitely
Yes, for a specified period of time
No

How long do you want to have artificial nutrition or hydration continued? (Days, Weeks, Months)

Advance Medical Directive / Health Care Directive (also known as a "Living Will")

Step 1 of 3

Terminal Condition

Persistent Vegetative State (CO) / Permanent Unconscious Condition (WA)

Other Directions

Resolution with Medical Power of Attorney

HIPAA Release and Communications

Full Name	Relationship to You	Telephone Number