Vermont Advance Directive For Health Care Page 4
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8ADVANCE DIRECTIVE, PAGE 2
NAME _________________________________________________________________________ DOB ______________________ DATE __________________
Those who should NOT be consulted include:
I want my Advance Directive to start:
when I cannot make my own decisions
Now
when this happens: _______________________________________________________________
p
t
: H
c
g
s
w
art
wo
EaltH
arE
oals and
piritual
isHEs
My overall health care goals include:
I want to have my
I only want
I want treatment to sustain my life only if I will:
life sustained as
treatment
be able to communicate with friends and family.
long as possible by
directed
be able to care for myself.
any medical means.
toward my
live without incapacitating pain.
comfort.
be conscious and aware of my surroundings.
Additional Goals, wishes, or Beliefs I wish to express include:
People to notify if I have a life-threatening illness:
If I am dying it is important for me to be (check choice):
At home
In the hospital
Other:
________________________________________________________________________________________________________________
No preference
My Spiritual Care Wishes include:
My Religion/Faith:
___________________________________________________________________________________________________________
PLACE OF wORSHIP ______________________________________________________________________________ PHONE ________________________________
ADDRESS _____________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
The following items or music or readings would be a comfort to me:
______________________________________________________________________________________________________________________________________________
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