^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_ND05
3Do you wish to include this severability provision?
{NEXT_?}
Life-prolonging treatment should be withheld or withdrawn.Life-prolonging treatment should be used.I make no statement concerning life-prolonging treatment.
LIW_ND01
pIf you have been diagnosed with a terminal condition, what are your wishes concerning life-prolonging treatment?
Enter an X if the Declarant desires that life-prolonging treatment be withdrawn or withheld if two physicians certify that the Declarant is in a terminal condition with no hope of recovery. Press [Ctrl+F1] for more information. This provision must be initialed by the Declarant when the Living Will is signed.
Enter an X if the Declarant desires that life-prolonging treatment NOT be withdrawn or withheld if two physicians certify that the Declarant is in a terminal condition with no hope of recovery. Press [Ctrl+F1] for more information. This provision must be initialed by the Declarant when the Living Will is signed.
Enter an X if the Declarant has no preference regarding the withdrawal or withholding of life-prolonging treatment. Press [Ctrl+F1] for more information. This provision must be initialed by the Declarant when the Living Will is signed.
WND01007
{NEXT_?}
Yes, life-prolonging treatment should be withheld or withdrawn.
LIW_ND01
dIs it your desire that your life NOT be prolonged if you are in a permanently unconscious condition?
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I wish to receive nutrition.I wish to receive nutrition unless I cannot physically assimilate nutrition, nutrition would be harmful or painful, or nutrition would only prolong the dying process.I DO NOT wish to receive nutrition.I make no statement concerning the administration of nutrition.
LIW_ND02
jWhat decisions do you wish to make concerning the administration of NUTRITION when your death is imminent?
WND02005
I wish to receive hydration.I wish to receive hydration unless I cannot physically assimilate hydration, hydration would be harmful or painful, or hydration would only prolong the dying process.I DO NOT wish to receive hydration.I make no statement concerning the administration of hydration.
LIW_ND02
jWhat decisions do you wish to make concerning the administration of HYDRATION when your death is imminent?
{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_ND03
vIf you have been diagnosed as pregnant, do you desire that this Living Will be enforced if the fetus will not survive?
WND03003
Yes, if life-prolonging 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_ND03
|Should pain or physical harm be considered in determining whether life-prolonging treatment should be withheld or withdrawn?
{NEXT_?}
Yes, include the section.
LIW_ND03
LDo you wish to state the effectiveness of this document if you are pregnant?
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