^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_IN06
3Do you wish to include this severability provision?
{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 procedures, it is my preference that this document be given effect at that time.
LIW_IN03
sIf you have been diagnosed as pregnant, do you desire that this document be enforced if the fetus will not survive?
LFL04003
Yes, if life-prolonging 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_IN03
}Should pain or physical harm be considered in determining whether life-prolonging procedures should be withheld or withdrawn?
{NEXT_?}
Yes, include the paragraph.
LIW_IN03
LDo you wish to state the effectiveness of this document if you are pregnant?
LFL04002
{NEXT_?}
Name: |
LIW_IN01
+Who is this Living Will being prepared for?
{NEXT_?}
Yes, procedures should be withheld or withdrawn.
LIW_IN02
Is it your desire that your life NOT be prolonged by life prolonging procedures if you are in a permanently unconscious condition?
Enter an X to withdraw or withhold life prolonging procedures if the Declarant is permanently unconscious. Artificial nutrition provisions may also be initialed on the printed document.
4Who will be appointed as Health Care Representative?
Enter the Representative's name or use the P.I. Manager to select and paste a record. A "health care representative", or "proxy", is someone you designate to make health care decisions for you if you are unable to do so. Press [Ctrl+F1] for more information.
WIN05011
Yes, include Alternate Health Care Representative section.
LIW_IN05
ADo you wish to designate an Alternate Health Care Representative?
>Who will be appointed as Alternate Health Care Representative?
{NEXT_?}
Yes, include Representative section.
LIW_IN05
*Do you wish to designate a Representative?
WIN05001
{NEXT_?}
In the absence of my ability to give directions regarding the use of life-prolonging procedures, it is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences of the refusal.
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