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_PA07
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 treatment, it is my preference that this document be given effect at that time.
LIW_PA04
vIf you have been diagnosed as pregnant, do you desire that this Living Will be enforced if the fetus will not survive?
LNJ04003
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_PA04
|Should pain or physical harm be considered in determining whether life-sustaining treatment should be withheld or withdrawn?
{NEXT_?}
Yes, include the paragraph.
LIW_PA04
LDo you wish to state the effectiveness of this document if you are pregnant?
LNJ04002
{NEXT_?}
Name: |
LIW_PA01
+Who is this Living Will being prepared for?
{NEXT_?}
Yes, procedures should be withheld or withdrawn.
LIW_PA02
Is it your desire that your life NOT be prolonged by life sustaining procedures or treatment if you are in a permanently unconscious condition?
A Living Will directs the Declarant's physician to withdraw or withhold life sustaining procedures if the Declarant is in a terminal condition with no hope of recovery. Enter an X if the Declarant also wants such procedures withdrawn or withheld if he or she is permanently unconscious.
{NEXT_?}
YesNo
LIW_PA03
HDo you wish to receive artificially administered nutrition or hydration?
Enter an X if you WISH TO RECEIVE artificially administered nutrition and hydration, even though there is no hope of recovery from your condition.
Enter an X if you DO NOT WISH TO RECEIVE artificially administered nutrition and hydration if there is no hope of recovery from your condition.
{NEXT_?}
Yes, include the section.
LIW_PA03
PDo you wish to include information regarding artificial nutrition and hydration?
WPA03001
{NEXT_?}
YesNo
LIW_PA05
mDo you wish to receive CARDIAC RESUSCITATION if you have a terminal condition or are permanently unconscious?
WPA05003
YesNo
LIW_PA05
nDo you wish to receive MECHANICAL RESPIRATION if you have a terminal condition or are permanently unconscious?
WPA05005
YesNo
LIW_PA05
oDo you wish to receive BLOOD or BLOOD PRODUCTS if you have a terminal condition or are permanently unconscious?
WPA05007
YesNo
LIW_PA05
Do you wish to have SURGERY or INVASIVE DIAGNOSTIC TESTS performed if you have a terminal condition or are permanently unconscious?
WPA05009
YesNo
LIW_PA05
gDo you wish to receive KIDNEY DIALYSIS if you have a terminal condition or are permanently unconscious?
WPA05011
YesNo
LIW_PA05
cDo you wish to receive ANTIBIOTICS if you have a terminal condition or are permanently unconscious?
WPA05019
Other requests:#|
LIW_PA05
9What other specific requests or instructions do you have?
{NEXT_?}
WPA05019
Yes, include the section.
LIW_PA05
YDo you wish to state your specific desires regarding health care procedures or treatment?
Enter the Surrogate's name or use the P.I. Manager to select and paste a record. A "surrogate", 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.
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