Vermont Advance Directive For Health Care Page 5
Download a blank fillable Vermont Advance Directive For Health Care in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Vermont Advance Directive For Health Care with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8ADVANCE DIRECTIVE, PAGE 3
NAME _________________________________________________________________________ DOB ______________________ DATE __________________
______________________________________________________________________________________________________________________________________________
p
t
: l
t
art
HrEE
imitations of
rEatmEnt
You can decide what kind of treatment you want or do not want at the end of your life. These
wishes can apply to all situations or to situations that you specify. Regardless of the treatment
limitations stated you have the right to adequate management for pain and other symptoms
(nausea, fatigue, shortness of breath) related to your illness. unless treatment limitations are
stated, the medical teams are required and expected to do everything possible to save your life.
1. If my heart stops: (choose one)
I DO want CPR done to try to restart my heart.
I DON’T want CPR done to try to restart
my heart.
CPR means cardio (heart)-pulmonary (lung) resuscitation, including vigorous compressions of the
chest, use of electrical stimulation, medications to support or restore heart function, and rescue
breaths (forcing air into your lungs).
2. If I am unable to breathe on my own: (choose one)
I DO want a breathing machine
I want to have a breathing
I DO NOT want a breathing
without any time limit.
machine for a short time to see
machine for ANY length of
if I will survive or get better.
time.
“Breathing machine” refers to a device that mechanically moves air into and out of your lungs such as
a ventilator.
3. If I am unable to swallow enough food or water to stay alive: (choose one)
I DO want a feeding tube
I want to have a feeding tube
I DO NOT want a feeding tube
without any time limits
for a short time to see if I will
for any length of time.
survive or get better.
NOTE: If you are being treated in another state your agent may not automatically have the authority to
withhold or withdraw a feeding tube. If you wish to have your agent decide about feeding tubes please
check the box below.
I authorize my agent to make decisions about feeding tubes.
4. If I am terminally ill or so ill that I am unlikely to get better: (choose one)
I DO want antibiotics or other
I DON’T want antibiotics or other
medication to fight infection.
medication to fight infection.
If you have stated you DO NOT want CPR, a breathing machine, a feeding tube, or antibiotics under any
circumstances, please discuss this with your doctor who can complete a DNR/COLST form to ensure you
don’t receive treatments you don’t want, particularly in an emergency situation. A DNR/COLST order will
be honored outside of the hospital setting.
(PART THREE CONTINuED NExT PAGE)
6/11
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal