I _________________ on this _____________ day of _____________ in the year ________, declare that it is not my wish to be kept alive by artificial means for a period of time exceeding ( ) 12 hours; ( ) 24 hours; ( ) 3 days; ( ) 1 week; ( ) 1 month; ( ) 6 months.
I define “artificial means” as:
( ) a machine respirator; ( ) a heart pump; ( ) a feeding tube; ( ) a colostomy tube;
( ) a hydration tube.
( ) I give the order to not resuscitate me should my heart fail.
I do ( ) I do not ( )want to be an organ/tissue donor. As an organ donor, artificial support may be maintained long enough for the organs to be removed.
I give full responsibility to __________________ or any of my children to enable this directive. By doing so they will be fulfilling one of my last requests.