The Will to Live form starts from the principle that the presumption should be for life. If you sign it without

writing any "SPECIAL CONDITIONS," you are giving directions to your health care provider(s) and health care

If you wish to refuse some specific medical treatment, the Will to Live form provides space to do so

("SPECIAL CONDITIONS"). You may make special conditions for your treatment when your death is imminent,

meaning you will live no more than a week even if given all available medical treatment; or when you are incurably

terminally ill, meaning you will live no more than three months even if given all available medical treatment. There

is also space for you to write down special conditions for circumstances you describe yourself.

The important thing for you to remember if you choose to fill out any part of the "SPECIAL CONDITIONS"

sections of the Will to Live is that you must be very specific in listing what treatments you do not want. Some

examples of how to be specific will be given shortly, or you may ask your physician what types of treatment might

be expected in your specific case.

Why is it important to be specific? Because, given the pro-euthanasia views widespread in society and

particularly among many (not all) health care providers, there is great danger that a vague description of what you

do not want will be misunderstood or distorted so as to deny you treatment that you do want.

Many in the medical profession as well as in the courts are now so committed to the quality of life ethic that

they take as a given that patients with severe disabilities are better off dead and would prefer not to receive either

life-saving measures or nutrition and hydration. So pervasive is this "consensus" that it is accurate to say that in

practice it is no longer true that the "presumption is for life" but rather for death. In other words, instead of

assuming that a now incompetent patient would want to receive treatment and care in the absence of clear evidence

to the contrary, the assumption has virtually become that since any "reasonable" person would want to exercise a

"right to die," treatment and care should be withheld or withdrawn unless there is evidence to the contrary. The

Will to Live is intended to maximize the chance of providing that evidence.

It is important to remember that you are writing a legal document, not holding a conversation, and not

writing a moral textbook. The language you or a religious or moral leader might use in discussing what is and is

not moral to refuse is, from a legal standpoint, often much too vague. Therefore, it is subject to misunderstanding

or deliberate abuse.

The person you appoint as your health care agent may understand general terms in the same way you do.

But remember that the person you appoint may die, or become incapacitated, or simply be unavailable when

decisions must be made about your health care. If any of these happens, a court might appoint someone else you

don't know in that person's place. Also remember that since the agent has to follow the instructions you write in

this form, a health care provider could try to persuade a court that the agent isn't really following your wishes. A

court could overrule your agent's insistence on treatment in cases in which the court interprets any vague language

you put in your "Will to Live" less protectively than you meant it.

So, for example, do not simply say you don't want "extraordinary treatment." Whatever the value of that

language in moral discussions, there is so much debate over what it means legally that it could be interpreted very

broadly by a doctor or a court. For instance, it might be interpreted to require starving you to death when you have

a disability, even if you are in no danger of death if you are fed.

For the same reason, do not use language rejecting treatment which has a phrase like "excessive pain,

expense or other excessive burden." Doctors and courts may have a very different definition of what is "excessive"

or a "burden" than you do. Do not use language that rejects treatment that "does not offer a reasonable hope of

benefit." "Benefit" is a legally vague term. If you had a significant disability, a health care provider or court might

think you would want no medical treatment at all, since many doctors and judges unfortunately believe there is no

"benefit" to life with a severe disability.

What sort of language is specific enough if you wish to write exclusions? Here are some examples of things

you might--or might not--want to list under one or more of the "Special Conditions" described on the form.

Remember that any of these will prevent treatment ONLY under the circumstances--such as when death is

imminent--described in the "Special Condition" you list it under. (The examples are not meant to be all inclusive--

just samples of the type of thing you might want to write.)

"Cardiopulmonary resuscitation (CPR)." (If you would like CPR in some but not all circumstances when

you are terminally ill, you should try to be still more specific: for example, you might write "CPR if

cardiopulmonary arrest has been caused by my terminal illness or a complication of it." This would mean that you

would still get CPR if, for example, you were the victim of smoke inhalation in a fire.) "Organ transplants."

(Again, you could be still more specific, rejecting, for example, just a "heart transplant.")

"Surgery that would not cure me, would not improve either my mental or my physical condition, would not

make me more comfortable, and would not help me to have less pain, but would only keep me alive longer."

"A treatment that will itself cause me severe, intractable, and long-lasting pain but will not cure me."

Under the "General Presumption for Life," of your Will to Live, you will be given medication necessary to

control any pain you may have "as long as the medication is not used in order to cause my death." This means that

you may be given pain medication that has the secondary, but unintended, effect of shortening your life. If this is

not your wish, you may want to write something like one of the following under the third set of "Special

Conditions" (the section for conditions you describe yourself):

"I would like medication to relieve my pain but only to the extent the medication would not seriously

threaten to shorten my life." OR "I would like medication to relieve my pain but only to the extent it is known, to a reasonable medical certainty, that it will not shorten my life."Think carefully about any special conditions you decide to write in your "Will to Live." You may want to show them to your intended agent and a couple of other people to see if they find them clear and if they mean the same thing to them as they mean to you. Remember that how carefully you write may literally be a matter of life or death--your own.

1. This document allows you to name an attorney-in-fact for health care (also called a

"health care agent") who will make health care decisions for you whenever you are unable to

make them for yourself. It also allows you to give instructions concerning medical treatment

decisions that the health care agent must follow. Any person who is 18 years of age or older

may name a health care agent through this document. You must sign and date this document in

the presence of two witnesses and then have it notarized by a Notary Public. The witnesses

must be with you when you have it notarized.

2. You must sign this document in the presence of two witnesses. The witnesses must not

be related to you by blood or by marriage (they must not be relatives of your spouse) and they

must not be entitled to inherit anything from you under your will or as an heir. They cannot be

people to whom you owe money, or who claim that you owe them money. Additionally, your

doctor, an employee of your doctor, or an employee of your health facility or nursing home can

not be your witnesses.

3. Your agent must be 18 years of age or older and must not be providing health care to you

for pay.

4. It is helpful to appoint successor health care agents, to take care of the possibility that

your first choice is unable to serve. There is a space on the form for you to name two

successors to the health care agent.

5. You should tell your doctor about this document and ask him or her to keep a copy of it

in your medical file.

6. Your health care agent's authority takes effect only when you no longer have the capacity

to make health care decisions.

7. This Health Care Power of Attorney becomes effective when and if the doctor(s) you

choose (by writing their name(s) in the provided space on the form) determine in writing that

you are unable to sufficiently understand or communicate your health care decisions. If the

doctor(s) you choose are unavailable or unable to make this determination, it will be made by

the doctor who is attending you. If you do not choose to write in a doctor on the basis of

religious or moral beliefs you may write in another person on the form who will serve to certify

in writing, before a notary public, that you lack the capacity to make your

own health care decisions. The person you write in must be a competent person 18 years of age

or older, not responsible for providing your medical health care (not your doctor, nor an

employee of your doctor, nor anyone who might receive payment for your health care costs),

and not your health care agent.

8. A properly signed and witnessed declaration will remain in effect until you revoke

(cancel) it. You may revoke this document at any time. The revocation may be made in any

way by which you are able to communicate your intent to revoke. If you choose your spouse as

your health care agent and you become divorced or legally separated, this document will be

automatically revoked unless you have chosen a successor health care agent(s) as provided on

the form. In that case, the successor will then become your health care agent.

9. This type of document has been authorized by North Carolina state law. North Carolina

law requires your health care agent to act with reasonable care in following your wishes.

Occasionally a person will want to protect the agent from legal accountability for non-willful

mistakes while he or she is acting as your agent. If you wish to do this you may want to include

a section such as the following under "Other Special Conditions" section C on page 3: "My

health care agent and my health care agent's estate, heirs, successors, and assigns are hereby

released and forever discharged by me, my estate, my heirs, successors, and assigns and

personal representatives from all liability and from all claims or demands of all kinds arising out

of the acts or omissions of my health care agent pursuant to this document, except for willful

misconduct or gross negligence."

10. By filling out this form, you automatically nominate your health care agent to serve also

as the guardian of your person if it becomes necessary for a court to name one. A guardian of

the person takes custody of you and takes care of your personal belongings, such as clothing,

furniture, and cars (but not of your real estate, bank accounts, or other assets.) The guardian

will be responsible for making decisions about your care, education, living situation, and your

physical, legal, and psychological health treatment and other professional care. If you do NOT

wish to have your agent serve as your guardian, please cross out section number 1

("Guardianship Provision") on page 3 and sign your name to the crossed out section.

11. You should periodically review your document to be sure it complies with your wishes.

Before making any changes, be aware that it is possible that the statutes controlling this

document have changed since this form was prepared. Contact the Will to Live Project by

be used.

12. If you have questions about this document, or want assistance in filling it out, please

consult an attorney.

Form prepared 2001

(Notice: This document gives the person you designate your health care agents broad powers to make

health care decisions for you, including the power to consent to your doctor not giving treatment or stopping

treatment necessary to keep you alive. This power exists only as to those health care decisions for which you

are unable to give informed consent.

This form does not impose a duty on your health care agent to exercise granted powers, but when a

power is exercised, your health care agents will have to use due care to act in your best interests and in

accordance with this document. Because the powers granted by this document are broad and sweeping, you

should discuss your wishes concerning life-sustaining procedures with your health care agent.

Use of this form in the creation of a health care power of attorney is lawful and is authorized pursuant to

North Carolina law. However, use of this form is an optional and nonexclusive method for creating a health

care power of attorney and North Carolina law does not bar the use of any other or different form of power of

attorney for health care that meets the statutory requirements. )

Name:                                                                                                                                

Home Address                                                                                                                                        

Home Telephone Number                                                                                        

Work Telephone Number                                                                            

as my health care attorney-in-fact (herein referred to as my "health care agent") to act for me in my name (in

any way I could act in person) to make health care decisions for me as authorized in this document.

If the person named as my health care agent is not reasonably available or is unable or unwilling to act

as my agent, then I appoint the following persons (each to act alone and successively, in the order named), to

serve in that capacity:  

    (Optional)

A  Name:                                                                                                                                

Home Address                                                                                                                                        

Home Telephone Number                                                                                        

Work Telephone Number                                                                            

B.  Name:                                                                                                                                

Home Address                                                                                                                                        

Home Telephone Number                                                                                        

Work Telephone Number                                                                            

Each successor health care agent designated shall be vested with the same power and duties as if originally

named as my health care agent.

2. Effectiveness of appointment.

(Notice: This health care power of attorney may be revoked by you at any time in any manner by which

you are able to communicate your intent to revoke to your health care agent and your attending physician.)

Absent revocation, the authority granted in this document shall become effective when and if the

physician or physicians designated below determine that I lack sufficient understanding or capacity to make or

communicate decisions relating to my health care and will continue in effect during my incapacity, until my

death. This determination shall be made by the following physician or physicians. (You may include here a

designation of your choice, including your attending physician, or any other physician. You may also name two

or more physicians, if desired, both of whom must make this determination before the authority granted to the

health care agent becomes effective.):

3. General statement of authority granted.

Except as indicated in section 4 below, I hereby grant to my health care agent named above full power

and authority to make health care decisions on my behalf, including, but not limited to, the following:

        A. To request, review, and receive any information, verbal or written, regarding my physical or mental

        B. To employee or discharge my health care providers.

        C. To consent to and authorize my admission to and discharge from a hospital, nursing or convalescent

                home, or other institution.

        D. To give consent for, to withdraw consent for, or to withhold consent for, X-ray, anesthesia,

                medication, surgery, and all other diagnostic and treatment procedures ordered by or under the 

                authorization of a licensed physician, dentist, or podiatrist. This authorization specifically includes 

                the power to consent to measures for relief of pain.

        E. To authorize the withholding or withdrawal of life-sustaining procedures when and if my physician

                determines that I am terminally ill, permanently in a coma, suffer severe dementia, or am in a persistent

                vegetative state. Life-sustaining procedures are those forms of medical care that only serve to artificially

                prolong the dying process and may include mechanical, dialysis, antibiotics, artificial nutrition and hydration,

                and other forms of medical treatment which sustain, restore or supplant vital bodily functions. Life-sustaining

                procedures do not include care necessary to provide comfort or alleviate pain.

        F. To exercise any right I may have to make a disposition of any part or all of my body for medical

                purposes, to donate my organs, to authorize an autopsy, and to direct the disposition of my remains.

        G. To take any lawful actions that may be necessary to carry out these decisions, including the granting

                of releases of liability to medical providers.

4. Special provisions and limitations.

(Notice: The above grant of power is intended to be as broad as possible so that your health care agents

will have authority to make any decisions you could make to obtain or terminate any type of health care. If you

wish to limit the scope of your health care agent's powers, you may do so in this section.)

In exercising the authority to make health care decisions on my behalf, the authority of my health care

agent is subject to the following special provisions and limitations (Here you may include any specific

limitations you deem appropriate such as: your own definition of when life-sustaining treatment should be

withheld or discontinued, or instructions to refuse any specific types of treatment that are inconsistent with your

religious beliefs, or unacceptable to you or any other reason.):

GENERAL PRESUMPTION FOR LIFE

I direct my health care provider(s) and health care agent to make health care decisions consistent with

my general desire for the use of medical treatment that would preserve my life, as well as for the use of medical

treatment that can cure, improve, or reduce or prevent deterioration in, any physical or mental condition.

Food and water are not medical treatment, but basic necessities. I direct my health care provider(s) and

health care agent to provide me with food and fluids orally, intravenously, by tube, or by other means to the full

extent necessary both to preserve my life and to assure me the optimal health possible.

I direct that medication to alleviate my pain be provided, as long as the medication is not used in order

to cause my death.

I direct that the following be provided:

* the administration of medication;

* cardiopulmonary resuscitation (CPR); and

* the performance of all other medical procedures, techniques, and technologies, including surgery,

-- all to the full extent necessary to correct, reverse, or alleviate life-threatening or health-impairing conditions,

or complications arising from those conditions.

I also direct that I be provided basic nursing care and procedures to provide comfort care.

I reject, however, any treatments that use an unborn or newborn child, or any tissue or organ of an

unborn or newborn child, who has been subject to an induced abortion. This rejection does not apply to the use

of tissues or organs obtained in the course of the removal of an ectopic pregnancy.

I also reject any treatments that use an organ or tissue of another person obtained in a manner that

causes, contributes to, or hastens that person's death.  The instructions in this document are intended 

to be followed even if suicide is alleged to be attempted at some point after it is signed.

I request and direct that medical treatment and care be provided to me to preserve my life without

discrimination based on my age or physical or mental disability or the "quality" of my life. I reject any action

or omission that is intended to cause or hasten my death.

I direct my health care provider(s) and health care agent to follow the above policy, even if I am judged

WHEN MY DEATH IS IMMINENT

    A. If I have an incurable terminal illness or injury, and I will die imminently--meaning that a reasonably

prudent physician, knowledgeable about the case and the treatment possibilities with respect to the medical

conditions involved, would judge that I will live only a week or less even if lifesaving treatment or care is

provided to me--the following may be withheld or withdrawn:

If I am pregnant, and I am not in the final stage of a terminal condition as defined above,

medical procedures required to prevent my death are authorized even if they may result in the death

of my unborn child provided every possible effort is made to preserve both my life and the life of my

unborn child.

WHEN I AM TERMINALLY ILL

    B. Final Stage of Terminal Condition. If I have an incurable terminal illness or injury and even though death is

not imminent I am in the final stage of that terminal condition--meaning that a reasonably prudent physician,

knowledgeable about the case and the treatment possibilities with respect to the medical conditions involved,

would judge that I will live only three months or less, even if lifesaving treatment or care is provided to me--the

following may be withheld or withdrawn:

IF I AM PREGNANT

    D. Special Instructions for Pregnancy. If I am pregnant, I direct my health care provider(s) and health care

agent(s) to use all lifesaving procedures for myself with none of the above special conditions applying if there is

a chance that prolonging my life might allow my child to be born alive. I also direct that lifesaving procedures

be used even if I am legally determined to be brain dead if there is a chance that doing so might allow my child

to be born alive. Except as I specify by writing my signature in the box below, no one is authorized to consent

to any procedure for me that would result in the death of my unborn child.

If it becomes necessary for a court to appoint a guardian of my person, I nominate my health care agent

acting under this document to be the guardian of my person, to serve without bond or security.

        A. No person who relies in good faith upon the authority of or any representations by my health care

agent shall be liable to me, my estate, my heirs, successors, assigns, or personal representatives, for actions or

omissions by my health care agent.

        B. The powers conferred on my health care agent by this document may be exercised by my health care

agent alone, and my health care agent's signature or act under the authority granted in this document may be

accepted by persons as fully authorized by me and with the same force and effect as if I were personally

present, competent, and act on my own behalf. All acts performed in good faith by my health care agent

pursuant to this power of attorney are done with my consent and shall have the same validity and effect as if I

were present and exercise the powers myself, and shall inure to the benefit of and bind me, my estate, my heirs,

successors, assigns, and personal representatives. The authority of my health care agent pursuant to this power

of attorney shall by superior to and binding upon my family, relatives, friends, and others.

        A. I revoke any prior health care power of attorney.

        B. My health care agent shall be entitled to sign, execute, deliver, and acknowledge any contract or

other document that may be necessary, desirable, convenient, or proper in order to exercise and carry out any of

the powers described in this document and to incur reasonable costs on my behalf incident to the exercise of

these powers; provided, however, that except as shall be necessary in order to exercise the powers described in

this document relating to my health care, my health care agent shall not have any authority over my property or

financial affairs.

        C. My health care agent and my health care agent's estate, heirs, successors, and assigns are hereby

released and forever discharge by me, my estate, my heirs, successors, and assigns and personal representatives

from all liability and from all claims or demands of all kinds arising out of the acts and omissions of by health

care agent pursuant to this document, except for willful misconduct or gross negligence.

        D. No act or omission of my health care agent, or any other person, institution, or facility acting in good

faith in reliance on the authority of my health care agent pursuant to this health cater power of attorney shall be

considered suicide, nor the cause of my death for any civil or criminal purposes, nor shall it be considered

unprofessional conduct or as lack of professional competence. Any person, institution, or facility against whom

criminal or civil liability is asserted because of conduct authorized by this health care power of attorney may

interpose this document as a defense.

8. Signature of principal.

By signing here, I indicate that I am mentally alert and competent, fully informed as to the contents of

this document, and understand the full import of this grant of powers to my health care agent.

(SEAL)

Your Signature                                                                                 Date

9. Signature of Witnesses.

I hereby state that the Principal,                                                     , being of sound mind, signed the foregoing health

care power of attorney in my presence, and that I am not related to the principal by blood or marriage, and I

would not be entitled to any portion of the estate of the principal under any existing will or codicil of the

principal or as an heir under the Interstate Succession Act, if the principal died on this date without a will. I also

state that I am not the principal's attending physician, nor an employee of the principal's attending physician,

nor an employee of the health facility in which the principal is a patient, nor an employee of a nursing home or

any group care home where the principal resides. I further state that I do not have any claim against the

principal.

Witness:         Date                                                                         Witness:         Date

STATE OF NORTH CAROLINA

COUNTY OF                                              

CERTIFICATE

I,                                                 , Notary Public for County, North Carolina, hereby certify                                                              that appeared before me and swore to me and to the witnesses in my presence

that this instrument is a health care power of attorney, and that he/she willingly and voluntarily made and

executed it as his/her free act and deed for the purposes expressed in it.

I further certify that                                                  and                                                 , witnesses, appeared before me and swore that they witnessed sign the attached health care power of attorney, believing him/her to be of sound mind; and also swore that at the time they witnessed the signing (i) they were not related within the third degree to him/her or his/her spouse, and (ii) they did not know nor have a reasonable expectation that they would be entitled to any portion of his/her estate upon his/her death under any will or codicil thereto then existing or under that Intestate Succession Act at it provided at that time, and (iii) they were not a physician attending him/her, not an employee of an attending physician, nor an employee of a health facility in which he/she was a patient, nor an employee of a nursing home or any group-care home in which he/she resided, and (iv) they did not have a claim against him/her. I further certify that I am satisfied as to the genuineness and due execution of the instrument.

This the day of                                                                     ,

Notary Public

My Commission Expires:

(A copy of this form should be given to your health care agent and any alternate named in this power of

attorney, and to your physician and family members.)

Form prepared 2001