61. THE MERCK MANUAL, Sec. 14, Ch. 170, Stupor And Coma persistent vegetative state is most common after severe head injury or globalanoxia (eg, from cardiac arrest) and has a poor prognosis for recovering http://www.merck.com/pubs/mmanual/section14/chapter170/170a.htm

This Publication Is Searchable The Merck Manual of Diagnosis and Therapy Section 14. Neurologic Disorders Chapter 170. Stupor And Coma Topics [General] [General] Stupor is unresponsiveness from which the patient can be aroused only briefly by vigorous, repeated stimulation. Coma is a state in which the patient is unarousable and unresponsive and any response to repeated stimuli is only primitive avoidance reflexes; in profound coma, all brain stem and myotatic reflexes may be absent. The alert state requires intact cognitive functions of the cerebral hemispheres and preservation of arousal mechanisms of the reticular activating system (an extensive network of nuclei and interconnecting fibers that occupies the gray matter core of the pons, midbrain, and posterior diencephalon). The system receives afferent impulses from many somatic, visceral, auditory, and visual sensory pathways and relays these impulses to intralaminar, paracentral, and thalamic nuclei. These nuclei activate areas widely distributed throughout the cerebral cortex. Feedback neural loops balance normal activity at every level. Disturbance of these functions impairs arousal, which may be brief or prolonged, mild or profound. Stupor and coma are extreme forms. Brief losses of arousalunconsciousnessoccur with syncope (see

62. Transamerica Reinsurance USE OF MRI IN PREDICTION OF RECOVERY FROM persistent vegetative state, One of themost difficult conditions to assess is persistent vegetative state (PVS). http://www.transamericareinsurance.com/news_articles_jim3doc2.asp

USE OF MRI IN PREDICTION OF RECOVERY FROM PERSISTENT VEGETATIVE STATE by Dr. Linda Goodwin, Vice President and Reinsurance Medical Director Reference: Kampfl A, Schmutzhard E, Franz G, Pfausler B, Haring HP, Ulmer H, Felber S, Golaszewski S, Aichner F. Prediction of recovery from post-traumatic vegetative state with cerebral magnetic-resonance imaging. Lancet 351: 1763-67, 1998. At one year, 42 patients remained in PVS and 38 showed some degree of recovery. Of the latter, recovery had started in 62% by 3 months and in 94% by 6 months. Two additional patients (6%) showed signs of recovery from 6 to 12 months after injury. Sixteen percent had a good recovery (all of whom began to recover within the first 6 months), 34% had severe disability, and 50% had moderate disability. On MRI, 98% of the PVS patients had lesions in the corpus callosum compared to 24% of the non-PVS group. Dorsolateral upper brainstem injury occurred in 74% of the PVS vs. 26% of the non-PVS group and injury to the corona radiata was found in 57% of the PVS group vs. 26% of the non-PVS group. There was no statistically significant difference in the frequency or location of injuries to the lobar white-matter, thalamus, hippocampus, or in cortical contusions, cerebral atrophy, brainstem atrophy, or ventricular enlargement between the two groups. PVS patients had more cerebral lesions (mean 10.4) compared to non-PVS patients (mean 7.9).

63. WASHMAN'S DOMAIN -- SAMPLE LIVING WILL 3. If I am in a persistent vegetative state, as determined by 2 physicians who havepersonally examined me, the following are my directions regarding the use http://my.execpc.com/~washman/sampleoflivingwill.html

SAMPLE COPY OF LIVING WILL The document shown below is to be used for demonstration purposes only. If you decide PLEASE BE SURE YOU READ THE FORM CAREFULLY AND UNDERSTAND IT BEFORE YOU COMPLETE AND SIGN IT DECLARATION TO PHYSICIANS 1. I, , being of sound mind, voluntarily state my desire that my dying may not be prolonged under the circumstances specified in this document. Under those circumstances, I direct that I be permitted to die naturally. If I am unable to give directions regarding the use of life-sustaining procedures or feeding tubes, I intend that my family and physician honor this document as the final expression of my legal right to refuse medical or surgical treatment and to accept the consequences from this refusal. 2. If I have a TERMINAL CONDITION, as determined by 2 physicians who have personally examined me, I do not want my dying to be artificially prolonged and I do not want life-sustaining procedures to be used. In addition, if I have such a terminal condition, the following are my directions regarding the use of feeding tubes (check only one): c. If I have not checked either box, feeding tubes will be used.

64. Living Will to use or not to use extreme lifesaving measures, such as life-support, if youare in an irrecoverable coma or in a persistent vegetative state. A Living http://www.livingtrustlawfirm.com/living_will1.htm

Living Will A Living Will orders a doctor to use or not to use extreme life-saving measures, such as life-support, if you are in an irrecoverable coma or in a "persistent vegetative state." A Living Will is sometimes mistakenly called a Do Not Resuscitate Order (DNR) because most people use this document to stop extreme life-saving measures. However, a true DNR is an order from a physician for other medical personnel (such as EMTs) to withhold life support. In a typical Living Will, doctors are ordered either to withhold life support or are requested to administer life support. Doctors are also ordered to withhold artificial nutrition or are ordered to give nutrition. Because the Living Will was drafted, signed and notarized while the patient was conscious and of sound mind, doctors must follow the directives of a Living Will document. This not only allows you to make these important decisions ahead of time, but it also removes the burden of making these difficult decisions from your loved ones. Additionally, it makes sure that the decisions you and your partner agree upon are not overruled by family members. Many prospective clients have said "Well, my partner knows what I want to have done let’s skip the Living Will." We respond by saying, "Do you really think your doctor will turn to your partner when a parent is standing there? Do you really expect your family to obey your partner when he or she tells them what to do? Even if they would, do you want your partner to think that they were responsible for your death for the rest of their lives so you can avoid paying for a Living Will?"

65. 1Up Health > Health Links Directory > Conditions And Diseases: Neurological Diso Sites. MCW HealthLink A look at coma and persistent vegetative state. Responding toPatients in the persistent vegetative state An Ethical and Legal Dilemma. http://www.1uphealth.com/links/chronic-damage-persistent-vegetative-state.html

Home Contact Us Privacy Caring For Your Well Being Alternative Medicine Clinical Trials Health News Poisons ... Health Topics A-Z Search 1Up Health Health Directory Addictions Alternative Animal ... Weight Loss By Demography Child Health Teen Health Men's Health Women's Health ... Chronic Damage : Persistent Vegetative State Description Sites MCW HealthLink A look at coma and persistent vegetative state. Includes a discussion on treatments and prognosis. NINDS Information Page Coma and persistent vegetative state data compiled by The National Institute of Neurological Disorders and Stroke. The Persistent Vegetative State Addresses the medical facts, describes the landmark cases that have led to research into this condition, defends the position that it is ethical and moral to discontinue life-sustaining treatment of patients, and offers links to other sources of information concerning this condition. Responding to Patients in the Persistent Vegetative State - An Ethical and Legal Dilemma. This article was published in Philosophia Christi 19.2 (Fall 1996): 55-83. This journal is a publication of the Evangelical Philosophical Society. World Medical Association WMA policy: Statement on persistent vegetative state. Includes a definition, recovery and guidelines.

66. Prediction Of Recovery From Post-traumatic Vegetative State With Cerebral Magnet Introduction. There is no more devastating or morally challenging conditionin modern medicine than the persistent vegetative state (PVS). http://www.univie.ac.at/vanswieten/preise/eisel4.html

Lancet - Volume 351, Number 9118 13 June 1998 Prediction of recovery from post-traumatic vegetative state with cerebral magnetic-resonance imaging Andreas Kampfl, Erich Schmutzhard, Gerhard Franz, Bettina Pfausler, Hans-Peter Haring, Hanno Ulmer, Stefan Felber, Stefan Golaszewski, Franz Aichner Department of Neurology (A Kampfl MD, E Schmutzhard MD, ,B Pfausler MD, H-P Haring MD, G Franz MD) Department of Biostatistics (H Ulmer PhD) , and Department of Magnetic Resonance and Spectroscopy (S Felber MD, S Golaszewski MD, F Aichner MD) , University Hospital Innsbruck, Innsbruck, Austria Correspondence to: Dr Andreas Kampfl, Department of Neurology, University Hospital Innsbruck, A-6020 Innsbruck, Austria Summary Introduction Patients and methods Results ... References Summary Background The early post-traumatic vegetative state (VS) is compatible with recovery. Various clinical and laboratory tests have failed to predict recovery so we assessed the value of cerebral magnetic-resonance imaging (MRI) in prediction of recovery. Methods 80 adult patients in post-traumatic VS had cerebral MRI between 6 weeks and 8 weeks after injury. MRIs were reviewed by three neuroradiologists for the number, sizes, and location of brain lesions. Three neurologists assessed the patients at the time of MRI and at 2 months, 3 months, 6 months, 9 months, and 12 months after injury using the Glasgow Outcome Scale.

67. Brain Injury Glossary P persistent vegetative state (PVS) A long-standing condition in which the patientutters no words and does not follow commands or make any response that is http://www.waiting.com/glossaryp.html

About Brain Injury A Glossary of Terms "P" Palliative Care Physiatrist Productive Activity Paraparesis ... PTA Click on a letter to access terms or click the "on" button to browse entire glossary. A B C D ... W Or Go To: Intracranial Pressure Understanding Coma Rancho Los Amigos Scale/ The Levels of Coma Objectives of Neurosurgery ... A Guide to Brain Anatomy Palliative Care - A program designed to reduce the severity of symptoms and/or decrease their impact on the individual, and to improve the quality of life. [Click Here To Return To List] Paraparesis - Weakness of the lower limbs. [Click Here To Return To List] Paraphasic Error - Substitution of an incorrect sound (e.g. , tree for free) or related word (e.g., chair for bed). [Click Here To Return To List] Paraplegia - Paralysis of the legs (from the waist down). [Click Here To Return To List] Parapnasias - Use of incorrect words or word combinations. [Click Here To Return To List] Parenteral - Not through the alimentary canal (gastrointestinal tract) but rather by injection through some other route, such as subcutaneous, intramuscular or intravenous. [Click Here To Return To List] Parietal Lobe - One of the two parietal lobes of the brain located behind the frontal lobe at the top of the brain.

68. Alterations Of Consciousness And Sleep Disorders - Internet Handbook Of Neurolog Glasgow Coma Scale eMedicine. Presistent Vegetative State/Apallic syndromepersistent vegetative state - Central Washington University; http://www.neuropat.dote.hu/coma.htm

Internet Handbook of Neurology Compiled by K atalin H Department of Neurology University of Debrecen, Hungary Coma Sleep Disorders Chapters: A Collection of High Quality Online Resources for Health Professionals Overview Consciousness and Neuroscience - Cerebral Cortex, 8:97-107, 1998 Coma and unconsciousness - Newcastle University, UK The Neurology of Impaired Consciousness - Cornell University Altered Mental Status and Coma - Pediatric Neurology, Emory University Approach to the Patient with an Altered Level of Consciousness - Praxis MD Approach to a Patient with Coma - Medical College of Georgia Evaluating the comatose patient - Postgraduate Medicine, February Coma Coma - Australian and New Zealand Intensive Care Society Coma - University of Utah, Houston Coma - Tulane University Coma - Shin Kong Wu Ho-Su Memorial Hospital, TW Altered Level of Counsciousness and Coma - Snow Tiger Medical Systems, 2000 Myxedema Coma: Diagnosis and Treatment - American Family Physician, December 2000 Conditions that resemble coma - University of Florida Coma Scales - The Medical Algorithms Project Glasgow Coma Scale Glasgow Coma Scale - Mestudents, BR

69. When Is Death This is a serious problem. In this country there are, at any one time, approximately10,000 individuals in comas or a persistent vegetative state. http://home.iatronet.net/Reflections/death2.htm

When Is Death I was only 24 years old the first time I was called upon to pronounce a person dead. It was during my fourth year in medical school and it was 3:00 a.m. Because all the physicians were in surgery, a nurse called me, an on-call medical student, to come to the bedside and make official what she had already diagnosed. Arriving at the bedside, I listened for heart sounds with my stethoscope but heard nothing. I watched for signs of breathing and saw none. I felt for pulses, but could not perceive any sign of life. Still insecure, I asked the nurse to get an electrocardiogram machine so I could make absolutely sure. I saw her roll her eyes upward as she left to comply with my request. I knew I was showing my inexperience, but I was worried that if I made a mistake and this man awoke in the morgue, I would never be able to forgive myself. So, I attached the EKG machine, checked the leads twice, and after seeing the persistent flat-line, finally wrote a brief note in the patients chart stating that he was indeed dead. Pronouncing that man dead over thirty years ago was not easy for me, and it seems little has changed. Today our society is still having a tough time defining death. For centuries death was defined by the cessation of breathing and heart beat. But in the 1950s modern medicine provided us with machines that take over these functions,and the old definition was no longer useful. This left us with a group of patients who were kept alive, yet considered brain dead.

70. Legislative Guide To End-of-Life Issues The term persistent vegetative state has long been used to describepatients who are awake but show no sign of awareness. In 1994 http://www.all.org/legislat/guide04.htm

"Permanent Vegetative State" Misnamed? The term "persistent vegetative state" has long been used to describe patients who are awake but show no sign of awareness. In 1994, a task force report endorsed by the American Academy of Neurology said the condition can be considered "permanent" if it lasts 12 months or more after traumatic injury. But recent evidence shows such predictions to be far from certain. The January 4 Journal of the American Medical Association reports on an 18-year-old woman who went into a "vegetative" state after a car accident, began emerging from the state only 15 months later, and was ultimately sent home from a long-term care facility (though still with severe disabilities) five years after the injury. The authors note that an earlier study by the Traumatic Coma Data Bank showed 6 of 25 such patients recovering awareness 1 to 3 years after their injury. They suggest "forgoing the use of the term 'permanent vegetative state' altogether" in medical practice. Noting that their patient, and others who have recovered after months in such states, have showed little distress at their ongoing disabilities, they comment: "Health care providers and the general public consider survival in a severely disabled state theoretically unacceptable, but it is much easier to conceptualize a 'life not worth living' when speaking in generalities and on broad matters of public policy than when making such a judgment for a particular patient" [Childs and Mercer, "Brief Report: Late Improvement in Consciousness After Post-Traumatic Vegetative State," JAMA, 1/4/96, pp.24-5 at 25]. Life at Risk, January, 1996

71. Dorlands Medical Dictionary persistent vegetative state, a condition of profound nonresponsiveness in the wakefulstate caused by brain damage at whatever level and characterized by a http://www.mercksource.com/pp/us/cns/cns_hl_dorlands.jspzQzpgzEzzSzppdocszSzuszS

72. How To Organize And Synthesize Information It became apparent that Nancy had virtually no chance of coming outof the persistent vegetative state into which she had lapsed. http://infocomp.csuchico.edu/metis/infolit/step4/tutorial_doc4_C4.htm

Euthanasia Simulation PART 3 In 1983, 25 year-old Nancy Cruzan, a Missouri resident, was transported to a hospital in an unconscious state after her car accidentally overturned. Because her brain had been anoxic for more than ten minutes, she fell into a coma. To aid in her recovery, physicians implanted gastronomy and hydration tubes into her. Nancy was later transferred to a state hospital. It became apparent that Nancy had virtually no chance of coming out of the persistent vegetative state into which she had lapsed. Her parents, who had been appointed as her co-guardians, believed that their self-respecting and independent daughter would not have wanted to continue her life under these circumstances. Nancy's parents asked employees of the state hospital to terminate the artificial nutrition and hydration procedures. The employees refused to honor the request without court approval. The U.S. Supreme Court decision, while not in favor of Nancy's parents, meant that the Cruzans could authorize the termination of nutrition and hydration procedures provided that there was clear and convincing evidence of what their daughter would have wanted should she fall into a persistent vegetative state. Later, three witnesses who knew Nancy very well came forward to testify in a rehearing of the case in a lower court. The witnesses remembered Nancy telling them that she absolutely would not want to continue her life as a "vegetable" hooked up to a machine. The court accepted the witnesses' statements as clear and convincing evidence. The court ordered the cessation of Nancy's nutrition and hydration. In December 1990, more than 7 years after her accident, Nancy was removed from her life-support system. She breathed her last breath 12 days later.

73. How Does A TBI Affect Consciousness? Generally, there are five abnormal states of consciousness that can result from aTBI stupor, coma, persistent vegetative state, lockedin syndrome, and brain http://www.braininjurydisorders.org/tbi_5.html

Who Suffers From TBI? What Are the Signs and Symptoms of TBI? What Are the Causes of and Risk Factors for TBI What Medical Care Should a TBI Patient Receive? ... How Can TBI be Prevented? How Does a TBI Affect Consciousness? A TBI can cause problems with arousal, consciousness, awareness, alertness, and responsiveness. Generally, there are five abnormal states of consciousness that can result from a TBI: stupor, coma, persistent vegetative state, locked-in syndrome, and brain death. Stupor is a state in which the patient is unresponsive but can be aroused briefly by a strong stimulus, such as sharp pain. Coma is a state in which the patient is totally unconscious, unresponsive, unaware, and unarousable. Patients in a coma do not respond to external stimuli, such as pain or light, and do not have sleep-wake cycles. Coma results from widespread and diffuse trauma to the brain, including the cerebral hemispheres of the upper brain and the lower brain or brainstem. Coma generally is of short duration, lasting a few days to a few weeks. After this time, some patients gradually come out of the coma, some progress to a vegetative state, and others die. Patients in a vegetative state are unconscious and unaware of their surroundings, but they continue to have a sleep-wake cycle and can have periods of alertness. Unlike coma, where the patient's eyes are closed, patients in a vegetative state often open their eyes and may move, groan, or show reflex responses. A vegetative state can result from diffuse injury to the cerebral hemispheres of the brain without damage to the lower brain and brainstem. Anoxia, or lack of oxygen to the brain, which is a common complication of cardiac arrest, can also bring about a vegetative state.

74. Declaration (Living Will): Questions & Answers - Cape Fear Valley Health System or not you want lifesustaining treatments or procedures administered to you if youare in a terminal and incurable condition or a persistent vegetative state. http://www.capefearvalley.com/declarationqa.htm

Q. What is a "Living Will"? A. A living will is a document that tells your doctor or other healthcare providers whether or not you want life-sustaining treatments or procedures administered to you if you are in a terminal and incurable condition or a persistent vegetative state. It is called a "living will" because it takes effect while you are still living. Q. Is a "Living Will" the same as a "Will" or "Living Trust"? A. No. Wills and living trusts are financial documents that allow you to plan for the distribution of your financial assets and property after your death. A living will only deals with medical issues while you are still living. Wills and living trusts are complex legal documents, and you usually need legal advice to execute them. You do not need a lawyer to complete your North Carolina living will. Q. When does a North Carolina Living Will go into effect? A. A North Carolina living will goes into effect when: 1) Your doctor has a copy of it, and 2) Your doctor has decided that you are no longer able to make your own health decisions, and 3) your doctor and another doctor have determined that you are in a terminal and incurable condition or a persistent vegetative state. Q.

75. HCE13b Suffering And Death, 13.6-13.7 persistent vegetative state (PVS) { 1 } patients have at least some periods ofconscious awareness and can respond to others at least by eye movements, but http://academic.uofs.edu/faculty/pm363/ME/hce13b02.htm

What is the best match? persistent vegetative state (PVS) - patients have at least some periods of conscious awareness and can respond to others at least by eye movements, but are otherwise paralyzed and unable to speak - patients can be physiologically stabilized for long periods, even years, but can have no psychic functions since these depend on higher brain centers - patients are totally unconscious as if asleep menu Directions: Click on a number from 1 to 3. 1 is wrong. Please try again. persistent vegetative state (PVS) - patients can be physiologically stabilized for long periods, even years, but can have no psychic functions since these depend on higher brain centers - patients are totally unconscious as if asleep menu 2 is correct! persistent vegetative state (PVS) - patients have at least some periods of conscious awareness and can respond to others at least by eye movements, but are otherwise paralyzed and unable to speak - patients are totally unconscious as if asleep menu Before continuing, you might try some wrong answers. 3 is wrong. Please try again.

76. HCE13b Suffering And Death, 13.6-13.7 { 1 } coma { 2 } - locked in state { 3 } - persistent vegetative state (PVS). { 1 } - coma { 2 } - locked in state { 3 } - persistent vegetative state (PVS). http://academic.uofs.edu/faculty/pm363/ME/hce13b03.htm

What is the best match? patients show signs of arousal and may grimace or make other reflex movements, but show no signs of awareness or response to communication - coma - locked in state - persistent vegetative state (PVS) menu Directions: Click on a number from 1 to 3. 1 is wrong. Please try again. patients show signs of arousal and may grimace or make other reflex movements, but show no signs of awareness or response to communication - locked in state - persistent vegetative state (PVS) menu 2 is wrong. Please try again. patients show signs of arousal and may grimace or make other reflex movements, but show no signs of awareness or response to communication - coma - persistent vegetative state (PVS) menu 3 is correct! patients show signs of arousal and may grimace or make other reflex movements, but show no signs of awareness or response to communication - coma - locked in state menu Before continuing, you might try some wrong answers. the end

77. Vegetative State Practice Note close to the patient cannot act as a veto to an application but they must be takenfully into account by the court Re G (persistent vegetative state) 1995 2 http://www.offsol.demon.co.uk/pract1fm.htm

Contents Objectives Legal Basis History ... HomePage Editor's Note: this Practice Note has been superseded by Appendix 2 of a new Practice Note on Medical and Welfare Decisions for Adults dated 1 May, 2001. PRACTICE NOTE OFFICIAL SOLICITOR TO THE SUPREME COURT: VEGETATIVE STATE 26 July 1996 The need for the prior sanction of a High Court judge The termination of artificial feeding and hydration for patients in a vegetative state will in virtually all cases require the prior sanction of a High Court judge: Airedale NHS Trust v Bland [1993] AC 789, 805 per Sir Stephen Brown P, and Frenchay Healthcare NHS Trust v S [1994] 1 FLR 485. Applications to court Applications to court should be by originating summons issued in the Family Division of the High Court seeking a declaration in the form set out in para (5) below. Subject to specific provisions below, the application should follow the procedure laid down for sterilisation cases by the House of Lords in Re F (Mental Patient: Sterilisation) [1990] 2 AC 1, [1989] 2 FLR 376 and in the Practice Note - Official Solicitor: Sterilisation (June 996) [1996] 2 FLR 111. Applications to court in relation to minors should be made within wardship. In such cases the applicant should seek the leave of the court for the termination of feeding and hydration, rather than a declaration. The form of relief set out in para 5 below should be amended accordingly.

78. Wob - BEKIS: The Moral And Legal Issues Surrounding The Treatment And Health Car Translate this page BEKIS-Datenbankeintrag zu The Moral and Legal Issues Surrounding the Treatmentand Health Care of Patients in persistent vegetative state. http://wob.drze.de/Wob/de/view_content2/class146_id1076.html

Institut für Wissenschaft und Ethik (IWE) Projekt "The Moral and Legal Issues Surrounding the Treatment and Health Care of Patients in Persistent Vegetative State" Laufzeit: 1. Juni 1994 - 31. Mai 1997 Förderung: Europäische Kommission Leitung und Mitarbeiter(-innen) Beteiligt Prof. Andrew Grubb, Centre of Medical Law and Ethics, King's College London, Großbritannien (Koordinator) Dr. Keith Andrews, M.D., M.B.B.S., F.R.C.P., M.R.C.P., Royal Hospital for Neuro-disability, London, Großbritannien Dr. Dolores Dooley, Department of Philosophy, University College Cork, Irland Prof. Dr. jur. Dr. h.c. Albin Eser, M.C.J., Max-Planck-Institut für ausländisches und internationales Strafrecht, Freiburg i.Br. Tina Garanis-Papadatos, National School of Public Health, Athen, Griechenland Prof. Dr. phil. Dr. h.c. Ludger Honnefelder Prof. Bryan Jennett, C.B.E., M.D., F.R.C.S., Institute of Neurological Sciences, Glasgow, Großbritannien Dr. jur. Hans-Georg Koch, Max-Planck-Institut für ausländisches und internationales Strafrecht, Freiburg i.Br. Prof. Marie-Louise Lamau, Centre d'Éthique Médicale, Universität Lille, Frankreich

79. Aarogya.com The Wellness Site Legalities And Informatics - Ethics Manual. Irreversible Loss of Consciousness. Persons who are ina persistent vegetative state are unconscious but not brain dead. http://www.aarogya.com/legalitiesandinformatics/ethicse/ethics16.asp

80. Living Will Form by artificial nutrition or hydration if my condition is determined to be terminaland incurable or if I am diagnosed as being in a persistent vegetative state. http://www.tchospital.org/AddDir/Living Will.htm

Living Will Declaration Of A Desire For A Natural Death As Set Forth In The Right To A Natural Death Act I, , being of sound mind, desire that, as specified below, my life not be prolonged by extraordinary means or by artificial nutrition or hydration if my condition is determined to be terminal and incurable or if I am diagnosed as being in a persistent vegetative state. I am aware and understand that this writing authorizes a physician to withhold or discontinue extraordinary means or artificial nutrition or hydration in accordance with my specifications set forth below. Initial any of the following as desired: If my condition is determined to be terminal and incurable or if I should lapse into a persistent vegetative state, I authorize the following: My physician may withhold or discontinue extraordinary means only. _ In addition to withholding or discontinuing extraordinary means, if such are necessary, my physician may withhold or discontinue either artificial nutrition or hydration, or both. If my physician determines that I am in a persistent vegetative state, I authorize the following:

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