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If at any time I have a terminal condition, end stage condition, or am in a persistent vegetative state, and if my attending or treating physician and another consulting physician have determined that there is no medical probability of my recovery from such condition, I direct that life-prolonging procedures, including without limitation the measures initialed in items 1 – 3 below, be withheld or withdrawn when the application of such procedures would serve only to prolong artificially the process of dying, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain.

 Measures of artificial life-support in the face of impending death that I specifically refuse are (those to which I affix my initials):
 ________ (1)   mechanical respiration when I am no longer able to sustain my own breathing;
 ________ (2)   nasogastric or other feeding tube when I am paralyzed or unable to take nourishment by mouth;
 ________ (3)   electrical or mechanical resuscitation of my heart when it has stopped beating.

 

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 to accept the consequences for such refusal.