If my physician believes that a certain life prolonging procedure or other health care treatment may provide me with comfort, relieve pain, or lead to a significant recovery, I direct my physician to try the treatment for a reasonable period of time. However, if such treatment proves to be ineffective, I direct treatment be withdrawn even if so doing may shorten my life. I be given health care treatment to relieve pain or to provide comfort even if such treatment might shorten my life, suppress my appetite or my breathing, or be habit-forming. When any of the above conditions exist, I DO NOT WANT the life prolonging procedures which I have initialed below. You may revoke or change this document at any time.
Periodic review is recommended.
If there are no changes after each review, initial and date in the margin.