^What other specific requests or instructions, if any, do you wish to include in this document?
If desired, use this space to state any other specific requests or instructions.
{NEXT_?}
LAL05255
SEVERABILITY. If any provision in this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
LIW_AZ05
3Do you wish to include this severability provision?
{NEXT_?}
Name: |
LIW_AZ01
+Who is this Living Will being prepared for?
WAZ01004
Yes, treatment should be withheld or withdrawn.
LIW_AZ01
Is it your desire that your life NOT be prolonged by life-sustaining treatment if you are in an irreversible coma (or a persistent vegetative state)?
A Living Will directs the Principal's physician to withdraw or withhold life-sustaining treatment if the Principal is in a terminal condition with no hope of recovery. Enter an X if the Principal also wants such treatment withdrawn or withheld if he or she is in an irreversible coma (or a persistent vegetative state).
{NEXT_?}
cardiopulmonary resuscitationartificially administered food and fluidshospitalization (if at all avoidable)[other treatment]
LIW_AZ02
If there is no hope of recovery from your condition, which of the following treatments or procedures do you wish NOT TO RECEIVE?
Enter an X if you do not want cardiopulmonary resuscitation (for example, the use of drugs, electric shock and artificial breathing).
Enter an X to state some other procedure or treatment that you do not want. If you mark this box, you will be asked to specify the procedure or treatment you prefer not to receive.
WAZ02005
{NEXT_?}
I do not want to receive:#|
LIW_AZ02
=What other procedure or treatment do you not wish to receive?
{NEXT_?}
Yes, include the section.
LIW_AZ02
IDo you wish to state specific procedures that you do not want to receive?
WAZ02001
{NEXT_?}
Yes, if at any point it is determined that it is not possible that the fetus could develop to the point of live birth with continued application of life-sustaining treatment, it is my preference that this document be given effect at that time.
LIW_AZ03
vIf you have been diagnosed as pregnant, do you desire that this Living Will be enforced if the fetus will not survive?
WAZ03002
Yes, if life-sustaining treatment will be physically harmful or unreasonably painful to me, I request that such harm or pain be considered in determining whether this document shall be effective if I am pregnant.
LIW_AZ03
|Should pain or physical harm be considered in determining whether life-sustaining treatment should be withheld or withdrawn?
{NEXT_?}
Yes, include the section.
LIW_AZ03
dDo you wish to include information regarding the effectiveness of this document if you are pregnant?
kDo you wish to state that the Principal's family and medical personnel follow the terms of the Living Will?
Enter an X to state that, in the absence of your ability to give directions regarding life-sustaining treatment, it is your intention that this living will be honored as the final expression of your legal right to refuse medical or surgical treatment and accept the consequences from such refusal.
WAZ06004
WitnessNotary
LIW_AZ07
/Who will acknowledge the Principal's signature?
Enter an X if the signing of the Living Will will be acknowledged by a witness. The program allows you to include both witness and notary blocks if you are unsure as to who will acknowledge the signing. If you don't choose, the program assumes a witness will sign the document. Press [Ctrl+F1] for more information.
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