While one is fully rationale, we should complete the official forms for our state that name a person to make medical decisions when you are unable to, and any directives for the kind of care you want to receive and treatments you do not want. State Legislatures change the laws about these forms, so it is also important to be sure the forms you signed agree with current state requirements. In addition, an attorney friend prepared the following form, conferring with physicians, and distributes it in our area. He gave me permission to publish it here. You may print it.

If you want to use it, first check with your primary care physician and attorney. They may suggest changes. Sign and witness it, giving copies to those who need to have it.


A Personal Directive To My Family, Physician(s),
Caretakers, And Agent Concerning A Good Death

A. I have tried to lead a good life and, like all generally rational people, I desire a good death when that time comes. I hope that it will be swift, without excessive pain, peaceful, and that those I love will be with me so that we can say our good-byes and so I can receive their support, preferably in a comfortable and familiar environment. I know that all does not go as we wish or as we plan, so I have set down this statement of my wishes in the hope that doing so will enable me to achieve a good death. I make this Personal Directive at a time when I am mentally competent and after much study and thought.
B. The Directive to Physicians, Family, and Surrogates I have executed makes clear that should I have a terminal condition or an irreversible condition, I do not want to receive life-sustaining procedures that will serve only to prolong my dying. This situation is relatively easy to manage in comparison to other physical or mental conditions that will rob me of dignity, mental capacity, and all that is meaningful to my life. For this reason, I have executed a Worksheet for Planning Medical Decisions which is attached to this Directive. I direct that that document be honored.
C. Still, there are two other types of debilitating conditions that will keep me from continuing to live a good life and have a good death.

In both of these two situations, after the conditions described above have been confirmed by a physician, I will need assistance in dying, but I do not want to endanger anyone or cause them to suffer prosecution by the government for assisting in ending my life. To this end, I have formulated the following guidelines and a directive which I hope will enable my family, friends, and agent to help me achieve a good death without the danger or the reality of criminal sanction.

Guidelines for a Good Death Under the Circumstances Described Above, with appropriate Directive:
1. The best and legally safest course of action is to prohibit anyone from feeding or hydrating me, or providing artificial nutrition and hydration. I should be able to die relatively peacefully and without pain or discomfort. I consider nutrition and hydration, whether natural or artificial, to be medical treatments or therapy under the circumstances described in this directive and I have determined that they are not acceptable medical treatments or therapy for me under the circumstances described above.
2. If my condition becomes painful at any time during the course I have described above; causes me discomfort (including stiffening or grimacing spontaneously); or I become confused and agitated; have hallucinations; experience delirium; suffer dyspnea; have unrelenting, persistent, unacceptable symptoms, such as extreme fatigue, weakness, or debility; or have seizures, I want to receive palliative care, including terminal sedation if necessary, sufficient to eliminate the symptoms described above, even if the medications hasten the moment of my death.
3. While this option may require finding an understanding physician if the physician-in-charge will not honor my wishes, this method should be possible to carry out with minimal conflict and difficulty.
4. It may be possible to receive hospice care during this period of dying, so long as hospice is committed to carrying out my wishes.
5. No one will need to do anything except assure that my wishes to receive no food or hydration, or artificial nutrition or hydration are honored. If I am mentally competent and able to communicate my wishes by some reliable means, I should be asked only whether I want to have this directive carried out. The details should not be discussed with me if I reach this point.

DIRECTIVE: To assist me with carrying out these wishes under the circumstances described above in paragraph C, I direct that no one be permitted to offer me food, liquids, artificial nutrition, or hydration by medical means unless I request it; nor may anyone bring food into my presence or within range of my ability to smell it or see it. The use of cracked ice by mouth to relieve any dryness around my lips and mouth is acceptable care, however, as are other treatments for such dryness. If I am able to swallow, and taking medication by mouth is appropriate, I may take fluids only as are necessary for the administration of the medication.

Sign and date

Witnesses and date