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_MN10
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_MN10
}Should pain or physical harm be considered in determining whether life-sustaining procedures should be withheld or withdrawn?
{NEXT_?}
Yes, include the section.
LIW_MN10
LDo you wish to state the effectiveness of this document if you are pregnant?
LAL04002
{NEXT_?}
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_MN11
3Do you wish to include this severability provision?
{NEXT_?}
This section states what effect this document has on your health care. The Declarant must read this section on the printed document before signing the Living Will. If you do not understand any of this information, ask an attorney to explain it to you.
LIW_MN01
{NEXT_?}
Name: |
LIW_MN02
+Who is this Living Will being prepared for?
{NEXT_?}
Life-sustaining treatment should be withheld or withdrawn.[Enter your wishes in your own words.]
LIW_MN03
What are your wishes concerning life-sustaining treatment if two physicians have determined that you have a terminal condition?
Enter an X if you want to have life-sustaining treatment withheld or withdrawn if two physicians have determined that your death will occur with or without life-sustaining treatment, and the application of such treatment would serve only to artificially prolong the dying process. Press [Ctrl+F1] for more information.
Enter an X if you prefer to specify in your own words your feelings and wishes regarding your health care if you have a terminal condition.
WMN03006
WMN03002
Yes, include "terminal condition" statement
LIW_MN03
QDo you wish to include a statement which clarifies the term "terminal condition"?
Enter an X if you want to specify whether the term "terminal condition" includes a permanently unconscious condition.
WMN03003
{NEXT_?}
"Terminal condition" INCLUDES a permanently unconscious condition."Terminal condition" DOES NOT INCLUDE a permanently unconscious condition.
LIW_MN03
THow do you want the term "terminal condition" to be interpreted in this Living Will?
Enter an X if you DO WANT the term "terminal condition" to include a permanently unconscious condition or coma.
Enter an X if you DO NOT WANT the term "terminal condition" to include a permanently unconscious condition or coma.
{NEXT_?}
LIW_MN03
wWhat are your wishes concerning your treatment if you are in a terminal condition or permanently unconscious condition?
{NEXT_?}
Treatment desired:#|
LIW_MN04
;What types of health care treatment do you wish to receive?
WMN04004
Treatment NOT desired:#|
LIW_MN04
?What types of health care treatment do you NOT wish to receive?
Use this space to explain types of care that you generally wish NOT TO RECEIVE. You are not required to make an entry. The next section concerns health care treatment that you do or do not wish to receive if you are certified to have a terminal condition.
{NEXT_?}
Treatment desired:#|
LIW_MN05
\What types of health care treatment do you wish to receive if you have a terminal condition?
WMN05005
Treatment NOT desired:#|
LIW_MN05
`What types of health care treatment do you NOT wish to receive if you have a terminal condition?
{NEXT_?}
[Include nutrition/hydration paragraph.][Enter your wishes in your own words.]
LIW_MN06
wDo you want to include a statement regarding artificial nutrition and hydration or enter your wishes in your own words?
Enter an X if you prefer to specify in your own words your feelings and wishes regarding artificial nutrition and hydration if you have a terminal condition.
WMN06005
WMN06002
I wish to receive artificial nutrition and hydration.I do not wish to receive artificial nutrition and hydration.
LIW_MN06
dWhat are your wishes concerning artificial nutrition and hydration if you have a terminal condition?
{NEXT_?}
LIW_MN06
xWhat are your wishes concerning artificial nutrition and hydration if you are terminally ill or permanently unconscious?
{NEXT_?}
LIW_MN07
HWhat are your values and preferences regarding health care instructions?
Use this space to specify any personal values or preferences values which you feel are relevant to the health care instructions stated in this Living Will (for example, religious beliefs or philosophy). Press [Ctrl+F1] for more information.
Enter the Proxy's name or use the P.I. Manager to select and paste a record. A "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.
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