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Page 1 of 5
MY LAST WISHES
(In the event of irreversible cognitive decline)
Please sign and date each page.
 I.
This section can be included in a regular advance directive.
I, ___________________________________________________________, as a person of clear and sound mind and under no coercion, endorse the items initialed on this directive. Ido so with the understanding that there is a chance that none of these eventualities will befallme or that they all might. My wishes stated here have been carefully considered._____ They have been discussed with the person(s) whom I have appointed as my healthcare Agent and my alternates._____ My Agent and my alternates agree with my wishes.These provisions cannot cover all possibilities, but they particularly apply to irreversiblebrain conditions such as dementia where there is a strong likelihood that cognitive functioncannot be restored, where I cannot speak for myself, and where there is no life support todisconnect so that death could occur easily.I would ask that you respect my view of dying and death and not try to impose yourphilosophy or beliefs on me, no matter how well meaning. Quality of life and autonomousdecision-making are high priorities for me._____ Generally, I wish to die with dignity and in peace. It is important for me to know thatI will not have to die a lingering and/or demeaning death or endure a hopeless andseverely disabling condition that would involve great and irremediable suffering formyself and/or those I love. It is consistent with my ethical view for me to choosewhen and how I die and to seek help in carrying out that decision._____ To further indicate that this is an enduring request, I have been a member of _______________________________________________since ___________________._____ It should be clear that despite my wishes to choose death when there is no hope forrecovery, I want the best possible medical care, including life-sustaining measures,when the prognosis appears to be favorable, if there is a reasonable chance that I willbe restored to independent living that has meaning and offers enjoyment._____ I do not want to be remembered as demented or severely impaired cognitively; Iwould prefer that my life end before that happens.Sign here_________________________________________ Date_______________
 
My Last Wishes Advance Directive
Page 2 of 5
Unacceptable conditions:These following conditions would be unacceptable to me. I want these wishes to go intoeffect when:_____ One of these situations exist_____ Two of these situations exist_____ Three or more of these situations exist_____ Other: ____________________________________________________________Sign here ______________________________________________ Date _________________ When I am diagnosed with an irreversible condition that will invariably cause a severedecline in my cognitive abilities_____ When I no longer recognize those I love_____ When I cannot care for my own needs_____ When I must go to a nursing home_____ When I cannot feed myself _____ When I become incontinent_____ When my behavior is often violent and disruptive_____ When I wander off frequently and am disoriented_____ Other: ____________________________________________________________When the stated number of conditions happens to me, I do not wish to use the resourcesnecessary to keep me alive. It would be best for me to die peacefully. I wish to be keptcomfortable, free of pain, and maintained in a dignified state, but want no measures taken toprolong my life.Sign here_________________________________________ Date_______________
 
My Last Wishes Advance Directive
Page 3 of 5
These include:_____ If I get an infection, do not treat it; just make me comfortable. No antibiotics._____ If I cannot feed myself, just leave the food for me. Do not spoon feed me orencourage me in any way to eat or drink._____ I clearly do not want artificial food or hydration._____ If I cannot breathe for myself, I refuse to be put on a ventilator._____ If my kidneys fail, I do not want dialysis._____ If I stop breathing or my heart stops beating, I do not want cardiopulmonaryresuscitation._____ I want no blood transfusions._____ I want all measures to keep me comfortable and pain free even – and especially if –they hasten my death._____ If I have a heart attack or stroke, do nothing to extend my life, but do provide comfortmeasures._____ I want no surgery unless it is absolutely necessary to control pain._____ I want no invasive diagnostic procedures._____ I do not want a tube inserted to admit air or administer food and hydration._____ I do not want to be treated in a hospital, but wish to be made comfortable where Ireside._____ Other: _________________________________________________________________ If any of these measures causes me to die sooner rather than later, that is my wish. Iwant enough medication to end my physical and psychological pain and sufferingeven if death is the result.Sign here _______________________________________________ Date ____________
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