STATEMENT OF MY WISHES

1. My proxy. I name [name, relationship, phone] as my health-care agent, and [name, phone] as my alternate. I want my proxy's decisions followed even if other members of my family disagree.

2. Authority. My proxy may make any health-care decision I could make, including to start, refuse, or stop any treatment, including artificial nutrition and hydration, [and to see my medical records and speak with any of my clinicians].

3. What I've told them. I've talked with my proxy about what matters to me. In short: [two or three sentences in my own words].

4. Comfort. Whatever else is decided, I want my pain and distress treated.

5. For my proxy. Decide as you believe I would. If you can't tell, decide what you believe is best for me. Whatever you decide, I've chosen you to decide it, and I'm grateful.