Advance Directive

MY LAST WISHES (In the event of irreversible cognitive decline) Please sign and date each page.

I. This section can be included in a regular advance directive. I, ___________________________________________________________, as a person of clear and sound mind and under no coercion, endorse the items initialed on this directive. I do so with the understanding that there is a chance that none of these eventualities will befall me or that they all might. My wishes stated here have been carefully considered. _____ They have been discussed with the person(s) whom I have appointed as my health care Agent and my alternates. _____ My Agent and my alternates agree with my wishes. These provisions cannot cover all possibilities, but they particularly apply to irreversible brain conditions such as dementia where there is a strong likelihood that cognitive function cannot be restored, where I cannot speak for myself, and where there is no life support to disconnect so that death could occur easily. I would ask that you respect my view of dying and death and not try to impose your philosophy or beliefs on me, no matter how well meaning. Quality of life and autonomous decision-making are high priorities for me. _____ Generally, I wish to die with dignity and in peace. It is important for me to know that I will not have to die a lingering and/or demeaning death or endure a hopeless and severely disabling condition that would involve great and irremediable suffering for myself and/or those I love. It is consistent with my ethical view for me to choose when and how I die and to seek help in carrying out that decision. _____ To further indicate that this is an enduring request, I have been a member of _______________________________________________since ___________________. _____ It should be clear that despite my wishes to choose death when there is no hope for recovery, I want the best possible medical care, including life-sustaining measures, when the prognosis appears to be favorable, if there is a reasonable chance that I will be restored to independent living that has meaning and offers enjoyment. _____ I do not want to be remembered as demented or severely impaired cognitively; I would prefer that my life end before that happens. Sign here_________________________________________ Date_______________ Page 1 of 5

My Last Wishes

Advance Directive

Unacceptable conditions: These following conditions would be unacceptable to me. I want these wishes to go into effect when: _____ One of these situations exist _____ Two of these situations exist _____ Three or more of these situations exist _____ Other: ____________________________________________________________

Sign here ______________________________________________ Date ____________

_____ When I am diagnosed with an irreversible condition that will invariably cause a severe decline in my cognitive abilities _____ When I no longer recognize those I love _____ When I cannot care for my own needs _____ When I must go to a nursing home _____ When I cannot feed myself _____ When I become incontinent _____ When my behavior is often violent and disruptive _____ When I wander off frequently and am disoriented _____ Other: ____________________________________________________________

When the stated number of conditions happens to me, I do not wish to use the resources necessary to keep me alive. It would be best for me to die peacefully. I wish to be kept comfortable, free of pain, and maintained in a dignified state, but want no measures taken to prolong my life.

Sign here_________________________________________ Date_______________

Page 2 of 5

My Last Wishes

Advance Directive

These include: _____ If I get an infection, do not treat it; just make me comfortable. No antibiotics. _____ If I cannot feed myself, just leave the food for me. Do not spoon feed me or encourage me in any way to eat or drink. _____ I clearly do not want artificial food or hydration. _____ If I cannot breathe for myself, I refuse to be put on a ventilator. _____ If my kidneys fail, I do not want dialysis. _____ If I stop breathing or my heart stops beating, I do not want cardiopulmonary resuscitation. _____ I want no blood transfusions. _____ I want all measures to keep me comfortable and pain free even – and especially if – they hasten my death. _____ If I have a heart attack or stroke, do nothing to extend my life, but do provide comfort measures. _____ I want no surgery unless it is absolutely necessary to control pain. _____ I want no invasive diagnostic procedures. _____ I do not want a tube inserted to admit air or administer food and hydration. _____ I do not want to be treated in a hospital, but wish to be made comfortable where I reside. _____ Other: ____________________________________________________________ _____ If any of these measures causes me to die sooner rather than later, that is my wish. I want enough medication to end my physical and psychological pain and suffering even if death is the result.

Sign here _______________________________________________ Date ____________

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My Last Wishes

Advance Directive

II. This section can be attached to your regular advance directive. It contains options which may not be legal. Stating them may protect someone who has elected to carry them out. Please initial the statements with which you agree. This amendment is a supplement to my Living Will and Durable Power of Attorney for Health Care. It is added to ensure that my additional wishes be known by all who may care for me. It should, in no way, negate my wishes stated in the above documents. _____ If my advance directive is negated because a judgment is made that I am now “happy” in my demented life, I authorize my estate and loved ones not to pay for any care received. I would prefer to be helped to die peacefully. _____ If I have the conditions I initialed above, I feel that it would not be desirable to continue my life. To me it would cease to have meaning and quality. I would prefer to have a gentle, quick, painless and certain death. If it is possible to get help to die, even if I am no longer competent to request it, this is what I want, either from a physician or from a friend. _____ If no one is able to care for me at home and admission to a nursing home is a necessity, I want to be taken care of in a hygienic and pain-free manner. I want to be kept comfortable until death occurs and would prefer that be as soon as possible. If I choose to hasten my death: _____ I want to know that comfort care is available to me. If I choose hospice care or some other means to relieve suffering, I still retain the option to hasten my death. I do not want any care denied simply because I have chosen to plan my death. _____ If I choose to stop eating and drinking, I do not want anyone to force-feed me or rehydrate me. Going against my wishes would constitute battery, no matter how benevolent the intention. _____ I want assistance in dying to be an option if I am suffering from an irreversible, progressive physical condition. If I am mentally and physically capable of selfdeliverance, I would like the support of an expert in directing the procedure and working with my loved ones. Anyone acting in this capacity is doing so at my request and with my gratitude. I want to make sure the legal system understands my intention. _____ If I am no longer capable of ending my own life and there is no hope for recovery to a meaningful existence, I want my health care agent to request assistance in dying for me if that is a legal option at that time. _____ Both parties – my agent and the persons who assist – are following my wishes and should be immune from civil or criminal penalties. Such assistance would constitute voluntary euthanasia because I am specifying the circumstances in advance and directing my health care agent to have my wishes carried out. Sign here for any current changes ____________________________ Date ___________ Page 4 of 5

My Last Wishes

Advance Directive

_____ If I choose to hasten my death, or have my life ended, I would like the cooperation of those close to me. If they cannot participate I would like them to keep their objections to themselves, not to interfere with my plans, and to remain silent about assistance that was graciously provided to me. _____ Other wishes: ______________________________________________________ Signed _____________________________________________ Date _______________ Printed Name ____________________________________________________________ Witness’ Signature ___________________________________Date ________________ Printed Name ____________________________________________________________ Witness’ Signature __________________________________ Date _________________ Printed Name ____________________________________________________________

To ensure this is a continuing wish, I have signed and dated this document as follows: _________________________________________________ Date __________________ _________________________________________________ Date __________________ _________________________________________________ Date __________________ _________________________________________________ Date __________________ _________________________________________________ Date __________________ _________________________________________________ Date __________________ _________________________________________________ Date __________________ Sign here for any current changes ____________________________________________ Date ____________ NOTE: Sign and date each page now. It is enormously important then to keep updating this document – at least once a year – adding your initials each time. This “Last Wishes” document is issued by the nonprofit Euthanasia Research & Guidance Organization (ERGO) 24829 Norris Lane, Junction City, Oregon 97448, USA [email protected] It can be downloaded for $5 from www.FinalExit.org It does not claim to be a 'legal document’ but is an intelligent, honest expression of a person’s wishes. 2004 Page 5 of 5