[Note: According to 20 Pa.C.S.A. § 5404(b), an advance directive for health care may (but need not be) in the following form. Click here for further information. This form is not legal advice and the publisher is not responsible for any errors or omissions or for any consequences of any reliance on it.]

                            DECLARATION


     I, _____________________________, being of sound mind, 
willfully and voluntarily make this declaration to be followed 
if I become incompetent.  This declaration reflects my firm and 
settled commitment to refuse life-sustaining treatment under the 
circumstances indicated below.

     I direct my attending physician to withhold or withdraw 
life-sustaining treatment that serves only to prolong the 
process of my dying, if I should be in a terminal condition or 
in a state of permanent unconsciousness.

     I direct that treatment be limited to measures to keep me 
comfortable and to relieve pain, including any pain that might 
occur by withholding or withdrawing life-sustaining treatment.

     In addition, if I am in the condition described above, I 
feel especially strongly about the following forms of treatment:

          I ( ) do ( ) do not want cardiac resuscitation.
          I ( ) do ( ) do not want mechanical respiration.
          I ( ) do ( ) do not want tube feeding or any other 
               artificial or invasive form of nutrition (food) 
               or hydration  (water).
          I ( ) do ( ) do not want blood or blood products.
          I ( ) do ( ) do not want any form of surgery or 
               invasive diagnostic tests.
          I ( ) do ( ) do not want kidney dialysis.
          I ( ) do ( ) do not want antibiotics.

I realize that if I do not specifically indicate my preference
regarding any of the forms of treatment listd above, I may
receive that form of treatment.

     Other instructions:

     I ( ) do ( ) do not want to designate another person as my 
surrogate to make medical treatment decisions for me if I should 
be incompetent and in a terminal condition or in a state of 
permanent unconsciousness.

    Name and address of surrogate  (if applicable):



    Name and address of substitute surrogate (if surrogate 
designated above is unable to serve):



     I made this declaration on __________________, 19___.

            Declarant's signature: ____________________________

              Declarant's address: ____________________________
                                   ____________________________


     The declarant knowingly and voluntarily signed this writing 
by signature or mark in my presence.

____________________________     ______________________________
Signature of Witness             Address of Witness


____________________________     ______________________________
Signature of Witness             Address of Witness

Evans Law Office
Daniel B. Evans, Attorney at Law
P.O. Box 27370
Philadelphia, PA 19118
Telephone: (866) 348-4250
Email: dan@evans-legal.com