Living Will

1. Legal Name 2. Street Address 3. City and state 4. Country 5. Male or female 6. Terminal Condition: do you want to receive life sustaining treatment if you are in a Terminal Condition with no hope of recovery and unable to communicate in any way? a.Yes, I want to receive life sustaining treatment b.NO c.I decline to choose a preference at this time.

7. Permanently Unconscious: Do you want to receive life sustaining treatment if you are in a Permanent unconscious Condition with no hope of recovery and unable to communicate in any way? a.Yes, I want to receive life sustaining treatment b.NO c.I decline to choose a preference at this time.

8. Tube Feeding: If you are diagnosed to be in a terminal condition or a permanent unconscious condition with no hope of recovery, do you want to receive artificially provided food and water? a. Yes, I want to receive food AND water b. Just water c. No, neither of there d. I decline to choose a preference at this time

9. Do you want to review the options for pregnancy in your Living Will? a. Yes b. No

10. Terminal Condition: in the event that you are in the final stages of a terminal condition with no hope of recovery and you are pregnant, do you want to receive life sustaining treatment? a. Yes, I want to receive life sustaining treatment b. No, I want to have the life sustaining procedures halted, even if halting them would result in the death of my unborn child c. I decline to choose a preference at this time

11. Not in Terminal Condition: If you are not in the final stages of a terminal condition, meaning that life sustaining measures can possibly allow recovery, but such measures might result in the death of your unborn baby, do you want your life preserved? a. Yes, I want to have my life preserved over that of my unborn baby b. No, I want my unborn baby’s life preserved over that of mine. c. I decline to choose a preference at this time.

12. Pain: In the event that you are in a terminal or permanent unconscious condition, are in severe pain, and unable to communicate, would you like to receive any and all pain medication even if the administration of it may lead to permanent physical damage, addiction or hasten the time of your death? a. Yes b. No c. I decline to choose a preference at this time

13. Do you want to be an organ donor? a. Yes b. No c. I decline to choose a preference at this time.

14. If yes to # 13, do you want to donate your organs for transplant purposes only, or would you consider donating your organs/body for scientific research as well? a. Transplant only b. Research only c. Both transplant and research

15. Have you appointed a health care agent in a separate Durable Power of Attorney? a. Yes b. No

16. Idaho allows you to appoint a patient advocate. This is someone who will be able to enforce your wishes under the living Will. This person must be a legal adult and is often a spouse, child, or other closer relative. Do you wish to appoint a patient advocate? a. Yes b. No 17. If yes to # 16 enter the name _______________