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

Additional Information

I indicate below whether I want nutrition (food) or hydration (water) medically

supplied by a tube through my nose, stomach, intestine, arteries, or veins if I

have an end-stage medical condition or I am permanently unconscious and there

is no realistic hope of significant recovery (initial your choice below):

I do want tube feedings to be given.

I do not want tube feedings to be given.

If I designated a healthcare agent in Part I, I indicate below whether my

healthcare agent must follow the instructions in this Part II if I am in an end-stage

medical condition or am permanently unconscious (initial your choice below):

My healthcare agent must follow the instructions in this Part II.

_____ My healthcare agent may use these instructions as guidance and

override any instructions I have given in this Part II.

I indicate below whether I want to donate my organs and tissues at the time of

my death for the purpose of transplant, medical study, or education (initial your

choice below):

I consent to donate my organs or tissues.

I do not consent to donate my organs or tissues.

PART III: SIGNATURE

Pennsylvania law protects my healthcare agent and healthcare providers from any legal liability for their good faith

actions in following my wishes as expressed in this document or in complying with my healthcare agent’s direction.

On behalf of myself, my executors, and heirs, I further hold my healthcare agent and my healthcare providers

harmless and indemnify them against any claim for their good faith actions in recognizing my healthcare agent’s

authority or in following my treatment instructions.

Having carefully read this document, I have signed it this _____ day of ___________, 20___, revoking all previous

healthcare powers of attorney and living wills.

(Signature)

Two witnesses at least 18 years of age are required by Pennsylvania law and should witness your signature in each

other’s presence. A person who signs this document on behalf of and at the direction of the principal may not be a

witness. It is preferable if the witnesses are not your heirs, nor your creditors, nor employed by any of your

healthcare providers).

(Witness Signature)

(Witness Printed Name)

(Witness Signature)

(Witness Printed Name)

Advance Healthcare Directive Form - Lancaster General Health Page 4