Advance Healthcare Directive Form - Lancaster General Health (Page 3 of 4) in pdf

Advance Healthcare Directive Form - Lancaster General Health Page 3

Additional Authority of My Healthcare Agent

If I suffer from severe and irreversible brain damage or brain disease with no

realistic hope of significant recovery, I would consider such condition intolerable and the

application of aggressive medical care to be burdensome. I therefore request that my

healthcare agent respond to any intervening life-threatening conditions in the same

manner as directed for an end-stage medical condition or state of permanent

unconsciousness as I have indicated in Part II. (Initial your choice below)

I Agree

I Disagree

Below, I list some things which are important to me and provide additional

instructions or directions to my healthcare agent:

PART II: LIVING WILL

The following healthcare treatment instructions exercise my right to make my own

healthcare decisions. These instructions are intended to provide clear and convincing

evidence of my wishes to be followed when I lack the capacity to understand, make, or

communicate my treatment instructions and I am permanently unconscious or in an

end-stage medical condition.

If I have an end-stage medical condition (which will result in my death, despite

the introduction or continuation of medical treatment) or am permanently

unconscious such as in an irreversible coma or an irreversible vegetative state,

and there is no realistic hope of significant recovery, then I choose the following

(initial your choice below):

I DO NOT want aggressive medical care and give the following

instructions:

I direct that I be given healthcare treatment to relieve pain or provide

comfort even if such treatment may shorten my life, suppress my appetite

or breathing, or be habit forming.

I direct that all life prolonging procedures be withheld or withdrawn.

I do not want any of the following life prolonging procedures: CPR;

mechanical ventilation; dialysis; surgery; chemotherapy; radiation

treatment; or antibiotics.

I DO want aggressive medical treatment and want my healthcare

team to attempt to prolong my life as long as possible within the limits of

generally accepted medical standards.

Advance Healthcare Directive Form - Lancaster General Health Page 3