To my family, doctors, hospitals, surgeons, medical care providers, and all others concerned with my care: I, Azalea Ikelyn R. de Leon, being of sound mind and rational thought, willfully and voluntarily make this declaration to be followed if I become incompetent or incapacitated to the extent that I am unable to communicate my wishes, desires and preferences on my own. This declaration reflects my firm, informed, and settled commitment to refuse life-sustaining medical care and treatment under the circumstances that are indicated below. This declaration and the following directions are an expression of my legal right to refuse medical care and treatment. I expect and trust the above-mentioned parties to regard themselves as legally and morally bound to act in accordance with my wishes, desires, and preferences. The above-mentioned parties should therefore be free from any legal liabilities for having followed this declaration and the directions that it contains. If the following conditions are present: 1. If I become terminally ill or permanently unconscious as determined by my personal physician, Dr. Joan Paula Pagalilauan, and at least one other physician; 2. If I am unable to participate indecisions regarding my medical care, and 3. Where I am unable to communicate my wishes and desires. I direct Marie Claire Alejandro and Charlotte Duran Sanchez to be my personal health nurses. I appoint Dr. Pagalilauan also, as my health care agent, with full power of attorney to make health care decisions based on this document and any views I may have previously expressed. In situations where my wishes are unknown, and she is to make decisions based on what she considers to be in my best interest and in keeping with my own personal values. I direct my personal physician or attending physician to withhold or withdraw life-sustaining medical care and treatment that is serving only to prolong the process of my dying if I should be in an incurable or irreversible mental or physical condition with no reasonable medical expectation of recovery. However, if there is possibility that I will recover, I desire that such life sustaining process will only last for 6 months. In such case, I would want to have a limited measure that would make me comfortable and for pain relief. I may change my mind at any time by communicating in any manner that this declaration does not reflect my wishes
Norman F. Dacey and Norman F. Dacey, Doing Business As National Estate Planning Council v. New York County Lawyers' Association, 423 F.2d 188, 2d Cir. (1970)