hospice,home care,terminal illness,dying,cancer,palliativeAdvance Directive for Health Care
 
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Advance Directive for Health Care

 

I, ______________________________________, write this document as a directive regarding my medical care.

 

In the following sections, put the initials of your name in the blank

spaces by the choices you want.

 

PART I. My Durable Power of Attorney for Health Care

 

______ I appoint this person to make decisions about my medical care if there ever comes a time when I cannot make those decisions myself. I want the person I appointed, my doctors, my family and others to be guided by decisions I have made in the parts of the form that follow.

 

Name:________________________________________________

 

Home

Telephone:_____________________________________________

 

Work

Telephone: ____________________________________________

 

Address: ______________________________________________

______________________________________________

 

If the person above cannot or will not make decisions for me, I appoint this person.

 

Name:________________________________________________

 

Home

Telephone:_____________________________________________

 

Work

Telephone: ____________________________________________

 

Address: ______________________________________________

______________________________________________

           

_______ I have not appointed anyone to make health care decisions for me in this or any other document.

 

PART 2. My Living Will

These are my wishes for my future medical care if there ever comes a time when I canít make these decisions for myself.

 

A. These are my wishes if I have a terminal condition.

 

Life-sustaining treatments

 

_______ I do not want life-sustaining treatments (including CPR) started. If life-sustaining treatments are started, I want them stopped.

 

_______ I want life-sustaining treatments that my doctors think are best for me.

 

_______ Other wishes. _______________________________

___________________________________________

 

Artificial nutrition and hydration

 

_______ I do not want artificial nutrition and hydration started if they would be the main treatments keeping me alive. If artificial nutrition and hydration are started, I want them stopped.

 

_______ I want artificial nutrition and hydration even if they are the main treatments keeping me alive.

 

_______ Other wishes. _______________________________

___________________________________________

 

Comfort care

 

_______ I want to be kept as comfortable and free of pain as possible, even if such care prolongs my dying or shortens my life.

 

_______ Other wishes. _______________________________

___________________________________________

 

 

B. These are my wishes if I am ever present in a persistent vegetative state.

 

Life-sustaining treatments

These are my wishes for my future medical care if there ever comes a time when I canít make these decisions for myself.

 

A. These are my wishes if I have a terminal condition.

 

Life-sustaining treatments

 

_______ I do not want life-sustaining treatments (including CPR) started. If life-sustaining treatments are started, I want them stopped.

 

_______ I want life-sustaining treatments that my doctors think are best for me.

 

_______ Other wishes. _______________________________

___________________________________________

 

Artificial nutrition and hydration

 

_______ I do not want artificial nutrition and hydration started if they would be the main treatments keeping me alive. If artificial nutrition and hydration are started, I want them stopped.

 

_______ I want artificial nutrition and hydration even if they are the main treatments keeping me alive.

 

_______ Other wishes. _______________________________

___________________________________________

 

Comfort care

 

_______ I want to be kept as comfortable and free of pain as possible, even if such care prolongs my dying or shortens my life.

 

_______ Other wishes. _____________________________        

 

 

C. Other Directions

 

You have the right to be involved in all decisions about your medical care, even those not dealing with terminal conditions or persistent vegetative states. If you have wishes not covered in other parts of this document, please indicate them below.

 

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

 

PART 3. Other Wishes

 

_______ I do not wish to donate any of my organs or tissues.

 

_______ I want to donate all of my organs and tissues.

 

_______ I only want to donate these organs and tissues:

 

               _________________________________________

 

_______ Other wishes.______________________________

_________________________________________

 

B. Autopsy

 

_______ I do not want an autopsy.

 

_______ I agree to an autopsy if my doctor recommends it.

 

_______ Other wishes.______________________________

_________________________________________

 

C. Other statements about your medical care

 

If you wish to say more about any of the choices you have made or if you have any other statements to make about your medical care, you may do so on a separate sheet of paper. If you do so, put here the number of pages you are adding: ________

 

PART 4. Signatures

 

You and two witnesses must sign this document before it will be legal.

 

A. Your signature

 

By my signature below, I show that I understand the purpose and the effect of this document.

 

Signature: _________________________  Date: _____________

 

Name Printed: ___________________________

 

Address: _____________________________________________

_____________________________________________________

 

B. Your witnessesí signatures

 

I believe the person who has signed this advanced directive to be of sound mind, that he/she signed or acknowledged this advance directive in my presence and that he/she appears not to be acting under pressure, duress, fraud or undue influence. I am not related the person making this advance directive by blood, marriage or adoption nor, to the best of my knowledge, am I named in his/her will. I am not the person appointed in this advance directive. I am not a health care provider or an employee of a health care provider who is now, or has been in the past, responsible for the care of the person making this advance directive.

 

Witness # 1

 

Signature: _________________________  Date: _____________

 

Name Printed: ___________________________

 

Address: _____________________________________________

_____________________________________________________

 

Witness # 2

 

Signature: _________________________  Date: _____________

 

Name Printed: ___________________________

 

Address: _____________________________________________

_____________________________________________________

 

 

Adapted with permission from the District of Colombia Hospital Association, 1250 Eye, N.W., Suite 700, Washington, DC

 

 

 

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