thank you for the site with the accurate format. However, it seems that the form Mae used was retyped from the printed form and apparently the person typing it errored in the placement of that phrase "to be withheld or withdrawn and that I be permitted to die". It shouldn't have remained attached to the last choice. It should have been separate following the choices.
I can only imagine how confused Mae might have been. If it were a test to evaluate one's mental capability, I would have failed.
(Hello, Dr.Feel Good. Can you reserve me a room at Loving Arms Hospice? I seem to have a mental disability. Oh, I don't? Only deminished capacity and that's terminal? Just put the X where? Oh, I see. I think I do anyway.)
The person also changed the wording on choice #2. Unless a person reading the form believed that people would rather be fed while they're dehydrated, rather than being hydrated while they're starved, I would expect such a person would perceive that "including" referred to services that should be provided, rather than services to be withheld.