STATEMENT OF MY WISHES

1. My proxy. I name [name, relationship, phone] as my health-care agent, and [name, phone] as my alternate if [he / she / they] cannot serve.

2. What I want. If I cannot speak for myself, I want every treatment that may prolong my life, including resuscitation, a breathing machine, dialysis, and artificial nutrition and hydration, for as long as my doctors believe it may keep me alive. [Exceptions, if any.]

3. When it stops. I want treatment continued until my doctors agree that it can no longer prolong my life, [and until my proxy agrees / and I ask that my proxy be given a second opinion before any treatment is withdrawn].

4. Comfort. I want my pain and distress treated, even while every other treatment continues.

5. What matters to me. [Faith, community, any clergy or tradition to be consulted. Where I want to be.]

6. For my proxy. When a question comes up that this document doesn't answer, choose the course more likely to keep me alive.
