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Living Will

  1. What is the patient's code status based on the living will below?

    1. Full Code
    2. DNR
    3. Unable to determine
  2. What is your next course of action for this patient?

    1. Defibrillate
    2. Do Not Defibrillate

(Answers at the Bottom)

Living Will

I, ______________________, being of sound mind, willfully, and voluntarily make this declaration to be followed if I become incompetent. This declaration reflects my firm and settled commitment to refuse life-sustaining treatment under the circumstances indicated below. I direct my attending physician to withhold or withdraw life-sustaining treatment that serves only to prolong the process of my dying, if I should be in a terminal condition or in a state of permanent unconsciousness. I direct that treatment be limited to measures to keep me comfortable and to relieve pain, including any pain that might occur by withholding or withdrawing life-sustaining treatment. In addition, if I am in the condition described above, I feel especially strong about the following forms of treatment:

I ( ) do (x) do not want cardiac resuscitation.

I ( ) do (x) do not want mechanical respiration.

I ( ) do (x) do not want tube feeding or any other artificial or invasive form of nutrition (food) or hydration(water).

I ( ) do (x) do not want blood or blood products.

I ( ) do (x) do not want any form of surgery or invasive diagnostic tests.

I ( ) do (x) do not want kidney dialysis.

I ( ) do (x) do not want antibiotics.

I realize that if I do not specifically indicate my preference regarding any of the forms of treatment listed above, I may receive that form of treatment.

Other Instructions:

I ( ) do ( ) do not want to designate another person as my surrogate to make medical treatment decisions for me if I should be incompetent and in a terminal condition or in a state of permanent unconsciousness. Name and address of surrogate (if applicable):

Name of Surrogate: ______________________

Address of Surrogate: ______________________

Name and address of substitute surrogate (if surrogate designated above is unable to serve):

Substitute Surrogate: ______________________

Address of Substitute: ______________________

I made this decision on the _________ day of _________(month), ___________ (year).

Declarant’s Signature: ______________________

Declarant’s Address: ______________________

The declarant or the person on behalf of and at the direction of the declarant knowingly and voluntarily signed this writing by signature or mark in my presence.

Witness’ Signature: ______________________

Witness’ Address: ______________________

Witness’ Signature: ______________________

Witness’ Address: ______________________



Question 1. (A) Full Code
Question 2. (A) Difibrillate

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