^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.
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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_SD07
3Do you wish to include this severability provision?
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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_SD05
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_SD05
|Should pain or physical harm be considered in determining whether life-sustaining treatment should be withheld or withdrawn?
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Yes, include the paragraph.
LIW_SD05
LDo you wish to state the effectiveness of this document if you are pregnant?
LNJ04002
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This is an important legal document. This document directs the medical treatment you are to receive if you are unable to participate in your own medical decisions and you are in a terminal condition. Prepare this document carefully. You may want to seek professional help to make sure the form does what you intend and is completed without mistakes. This document will remain valid and in effect until and unless you revoke it. Review this document periodically to make sure it continues to reflect your wishes. You may amend or revoke this document at any time by notifying your physician and other health-care providers. Please note that this document provides signature lines for you, two witnesses, and a notary public.
LIW_SD01
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Name: |
LIW_SD02
+Who is this Living Will being prepared for?
{NEXT_?}
[You must initial one of four program-supplied paragraphs regarding life-sustaining treatment or your own paragraph on the printed document. The other two program paragraphs are shown in the next question. You will be given an opportunity to write your own paragraph in a later question.]
NO LIFE-SUSTAINING TREATMENT. I direct that no life-sustaining treatment be provided. If life-sustaining treatment is begun, terminate it.
TREATMENT FOR RESTORATION. Provide life-sustaining treatment only if and for so long as you believe treatment offers a reasonable possibility of restoring to me the ability to think and act for myself.
LIW_SD03
WSD03001
[The two remaining program-supplied paragraphs are shown below.]
TREAT UNLESS PERMANENTLY UNCONSCIOUS. If you believe that I am permanently unconscious and this condition is irreversible, then do not provide me with life-sustaining treatment, and if such treatment is being provided to me, terminate it. If and so long as you believe that treatment has a reasonable possibility of restoring consciousness to me, then provide such treatment.
MAXIMUM TREATMENT. Preserve my life as long as possible, but do not provide treatment that is not in accordance with accepted medical standards as then in effect.
LIW_SD03
WSD03002
_____ (initials)#|
LIW_SD03
HWhat are your directives regarding the use of life-sustaining treatment?
If none of the previous options describes your wishes, use this space to enter your own specific directives regarding the use of life-sustaining treatment. If you write your own directives, you must initial this paragraph on the printed document.
{NEXT_?}
[Artificial nutrition and hydration is food and water provided through a nasogastric tube or tubes inserted into the stomach, intestines, or veins.]
With respect to artificial nutrition and hydration, I wish to make clear that: (initial only one)
I intend to include this treatment among the "life-sustaining treatment" that may be withheld or withdrawn.
I do not intend to include this treatment among the "life-sustaining treatment" that may be withheld or withdrawn.