DIRECTIVE TO PHYSICIANS AS PROVIDED BY CALIFORNIA HEALTH AND

SAFETY CODE SECTION 7187

DIRECTIVE TO PHYSICIANS

Directive made this _________________ day of ___________.

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:

1. If at any time I should have an incurable injury, disease,

or illness certified to be a terminal condition by two

physicians, and where the application of life-sustaining

procedures would serve only to artificially prolong the moment

of my death and where my physician determines that my death

is imminent whether or not life-sustaining procedures are

utilized, I direct that such procedures be withheld or

withdrawn, and that I be permitted to die naturally,

2. In the absence of my ability to give directions regarding

the use of such life-sustaining procedures, it is my intention

that this directive shall be honored by my family and

physician(s) as the final expression of my legal right to refuse

medical or surgical treatment and accept the consequences from

such refusal.

3. If I have been diagnosed as pregnant and that diagnosis is

known to my physician, this directive shall have no force or

effect during the course of my pregnancy.

4. I have been diagnosed and notified at least 14 days ago as

having a terminal condition by __________________, M.D. whose

address is ___________, __________.

I understand that if I have not filed in the physicians name and

address, it shall be presumed that I did not have a terminal

condition when I made out this directive.

5. This directive shall have no force and effect five years

from the date filled in above.

6. I understand the full import of this directive and I am

emotionally and mentally competent to make this directive.

_________________________________________________

The declarant has been personally known to me and

I believe him or her to be of sound mind.

Witness __________________________________________________

Witness __________________________________________________