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Part 1: INDIVIDUAL INSTRUCTIONS FOR HEALTH CARE
The following statements only apply
• if I am close to death and life support would only postpone the moment of my death OR
• if I am in an unconscious state such as an irreversible coma or a persistent vegetative state and it is unlikely that I will ever
become conscious OR
• if I have brain damage or a brain disease that makes me permanently unable to make and communicate health-care deci-
sions about myself.
(INITIAL ONLY ONE (1) CHOICE IN EACH SECTION and CROSS OUT ALL THAT DO NOT APPLY.)
A. CHOICETOPROLONGORNOTTOPROLONGLIFE
____YES, I do want to have my life prolonged as long as possible within the limits of generally accepted health-care