Living Will
Advance Directive: Treatment Preferences (“Living Will”) - You have the right to
use an advance directive to say what you want about future life-sustaining
treatment issues. It lets you decide about life-sustaining procedures in three
situations: when death from a terminal condition is imminent despite the
application of life-sustaining procedures; a condition of permanent
unconsciousness called a persistent vegetative state; and end-stage condition,
which is an advanced, progressive, and incurable condition resulting in complete
physical dependency. You may complete all or only part of the forms that you
use. Different forms may also be used.
A. Preference in Case of Terminal Condition
(If you want to state what your preference is, initial one only. If you do not want to
state a preference here, cross through the whole section.)
If my doctors certify that my death from a terminal condition is imminent, even if
life-sustaining procedures are used:
[ ] _____ 1. Keep me comfortable and allow natural death to occur. I do not
want any medical interventions used to try to extend my life. I do not want to
receive nutrition and fluids by tube or other medical means.
OR
[ x ] _____ 2. Keep me comfortable and allow natural death to occur. I do
not want medical interventions used to try to extend my life. If I am unable to
take enough nourishment by mouth, however, I want to receive nutrition and
fluids by tube or other medical means.
OR
[ ] _____ 3. Try to extend my life for as long as possible, using all available
interventions that in reasonable medical judgment would prevent or delay
my death. If I am unable to take enough nourishment by mouth, I want to
receive nutrition and fluids by tube or other medical means.
B. Preference in Case of Persistent Vegetative State
(If you want to state what your preference is, initial one only. If you do not want to
state a preference here, cross through the whole section.)
If my doctors certify that I am in a persistent vegetative state, that is, if I am not
conscious and am not aware of myself or my environment or able to interact with

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others, and there is no reasonable expectation that I will ever regain
consciousness:
[ x ] _____ 1. Keep me comfortable and allow natural death to occur. I do
not want any medical interventions used to try to extend my life. I do not
want to receive nutrition and fluids by tube or other medical means.
OR
[ ] _____ 2. Keep me comfortable and allow natural death to occur. I do not
want medical interventions used to try to extend my life. If I am unable to
take enough nourishment by mouth, however, I want to receive nutrition and
fluids by tube or other medical means.
OR
[ ] _____ 3. Try to extend my life for as long as possible, using all available
interventions that in reasonable medical judgment would prevent or delay
my death. If I am unable to take enough nourishment by mouth, I want to
receive nutrition and fluids by tube or other medical means.
C. Preference in Case of End-Stage Condition
(If you want to state what your preference is, initial one only. If you do not want to
state a preference here, cross through the whole section.)
If my doctors certify that I am in an end-state condition, that is, an incurable
condition that will continue in its course until death and that has already resulted
in loss of capacity and complete physical dependency:
[ ] _____ 1. Keep me comfortable and allow natural death to occur. I do not
want any medical interventions used to try to extend my life. I do not want to
receive nutrition and fluids by tube or other medical means.
OR
[ ] _____ 2. Keep me comfortable and allow natural death to occur. I do not
want medical interventions used to try to extend my life. If I am unable to
take enough nourishment by mouth, however, I want to receive nutrition and
fluids by tube or other medical means.
OR
[ x ] _____ 3. Try to extend my life for as long as possible, using all
available interventions that in reasonable medical judgment would prevent or

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delay my death. If I am unable to take enough nourishment by mouth, I want
to receive nutrition and fluids by tube or other medical means.
D. Pain Relief
No matter what my condition, give me the medicine or other treatment I need to
relieve pain.
E. In Case of Pregnancy
(Optional, for women of child-bearing years only; form valid if left blank)
If I am pregnant, my decision concerning life-sustaining procedures shall be
modified as follows:
If I am pregnant, I direct my health care provider(s) to use all lifesaving
procedures for myself if there is a chance that prolonging my life might allow my
child to be born alive. I also direct that lifesaving procedures be used even if I am
legally determined to be brain dead if there is a chance that doing so might allow
my child to be born alive.

F. Effect of Stated Preferences
(Read both of these statements carefully. Then, initial one only.)
[ ] _____ 1. I realize I cannot foresee everything that might happen after I
can no longer decide for myself. My stated preferences are meant to guide
whoever is making decisions on my behalf and my health care providers, but
I authorize them to be flexible in applying these statements if they feel that
doing so would be in my best interest.
OR
[ x ] _____ 2. I realize I cannot foresee everything that might happen after I
can no longer decide for myself. Still, I want whoever is making decisions on
my behalf and my health care providers to follow my stated preferences
exactly as written, even if they think that some alternative is better.
SIGNATURES AND WITNESSES
By signing below as the Declarant, I indicate that I am emotionally and mentally
competent to make this advance directive and that I understand its purpose and
effect. I also understand that this document replaces any similar advance
directive I may have completed before this date.

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Signature of Declarant _________________________
Date April 1, 2020
Print Name Cassandra Blake
The Declarant signed or acknowledged signing this document in my presence
and, based upon personal observation, appears to be emotionally and mentally
competent to make this advance directive.
Signature of Witness _________________________
Date April 1, 2020
Print Name Christopher Powell
Signature of Witness _________________________
Date April 1, 2020
Print Name Anna White

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