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 procedures, it is my preference that this document be given effect at that time.
LIW_CO04
vIf you have been diagnosed as pregnant, do you desire that this Living Will be enforced if the fetus will not survive?
LAL04003
Yes, if life-sustaining procedures 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_CO04
}Should pain or physical harm be considered in determining whether life-sustaining procedures should be withheld or withdrawn?
{NEXT_?}
Yes, include the section.
LIW_CO04
LDo you wish to state the effectiveness of this document if you are pregnant?
LAL04002
{NEXT_?}
Other requests:#|
LIW_CO05
^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_CO06
3Do you wish to include this severability provision?
{NEXT_?}
Name: |
LIW_CO01
+Who is this Living Will being prepared for?
WCO01005
Seven daysThe following number of days:
LIW_CO01
If two qualified physicians determine that you have an irreversible or incurable terminal condition, how many consecutive days should pass before life support is removed?
{NEXT_?}
Yes, it is my request that the term "terminal condition" be interpreted to include a state of permanent unconsciousness.
LIW_CO02
qDo you request that the term "terminal condition" be interpreted to include a state of permanent unconsciousness?
{NEXT_?}
NoYes (only for a limited time)Yes (indefinitely)
LIW_CO03
If you are terminally ill or permanently unconscious, do you wish to receive artificial nutrition and hydration if it is the only procedure being provided?
Enter an X to direct the discontinuance of artificial nutrition and hydration when it is the only procedure provided. The Declarant must initial this choice on the printed document.
Enter an X to direct the continuation of artificial nutrition and hydration for a specified number of days when it is the only procedure provided. You will then be asked to specify how long such treatment will continue. The Declarant must initial this choice on the printed document.
Enter an X to direct the continuation of artificial nutrition and hydration indefinitely when it is the only procedure provided. The Declarant must initial this choice on the printed document.
WCO03004
{NEXT_?}
LIW_CO03
hFor how many days will artificial nutrition and hydration continue if it is the only procedure provided?
{NEXT_?}
Yes, include the section.
LIW_CO03
PDo you wish to include information regarding artificial nutrition and hydration?
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