Death is as much a reality as birth, growth, maturity and old age.
It is the one certainty of life. Let this statement stand as an expression of my wishes now that I am still of sound mind, for the time when I may no longer take part in decisions for my own future. I do not fear death itself as much as the indignities of deterioration, dependence and hopeless pain. I therefore ask that medication be mercifully administered to me and that any medical procedures be performed on me which are deemed necessary to provide me with comfort, care or to alleviate pain. In the absence of my ability to give directions regarding the use of such life-prolonging procedures, it is my intention that this declaration shall be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences for such refusal.