Virginia Advance Directive For Health Care With Special Provisions For Mental Health Conditions Form Page 3
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4SECTION II: MY HEALTH CARE INSTRUCTIONS
[YOU MAY USE ANY OR ALL OF PARTS 1, 2 OR 3 IN THIS SECTION TO DIRECT YOUR HEALTH
CARE EVEN IF YOU DO NOT HAVE AN AGENT. IF YOU CHOOSE NOT TO PROVIDE WRITTEN
INSTRUCTIONS, DECISIONS WILL BE BASED ON YOUR VALUES AND WISHES, IF KNOWN, AND
OTHERWISE ON YOUR BEST INTERESTS. IF YOU ARE AN ORGAN, EYE OR TISSUE DONOR, YOUR
INSTRUCTIONS WILL BE APPLIED SO AS TO ENSURE THE MEDICAL SUITABILITY OF YOUR ORGANS,
EYES AND TISSUES FOR DONATION.]
1. I provide the following instructions in the event my attending physician determines that my death is imminent (very
close) and medical treatment will not help me recover:
[CHECK ONLY 1 BOX IN THIS PART 1.]
p I do not want any treatments to prolong my life. This includes tube feeding, IV fluids, cardiopulmonary
resuscitation (CPR), ventilator/respirator (breathing machine), kidney dialysis or antibiotics. I understand that I
still will receive treatment to relieve pain and make me comfortable. (OR)
p I want all treatments to prolong my life as long as possible within the limits of generally accepted health care
standards. I understand that I will receive treatment to relieve pain and make me comfortable. (OR)
p [YOU MAY WRITE HERE YOUR OWN INSTRUCTIONS ABOUT YOUR CARE WHEN YOU ARE
DYING, INCLUDING SPECIFIC INSTRUCTIONS ABOUT TREATMENTS THAT YOU DO WANT, IF
MEDICALLY APPROPRIATE, OR DON’T WANT. IT IS IMPORTANT THAT YOUR INSTRUCTIONS
HERE DO NOT CONFLICT WITH OTHER INSTRUCTIONS YOU HAVE GIVEN IN THIS ADVANCE
DIRECTIVE.]:
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______________________________________________________________________________________________________
2. I provide the following instructions if my condition makes me unaware of myself or my surroundings or unable to
interact with others, and it is reasonably certain that I will never recover this awareness or ability even with medical
treatment:
[CHECK ONLY 1 BOX IN THIS PART 2.]
p I do not want any treatments to prolong my life. This includes tube feeding, IV fluids, cardiopulmonary
resuscitation (CPR), ventilator/respirator (breathing machine), kidney dialysis or antibiotics. I understand that I
still will receive treatment to relieve pain and make me comfortable. (OR)
p I want all treatments to prolong my life as long as possible within the limits of generally accepted health care
standards. I understand that I will receive treatment to relieve pain and make me comfortable. (OR)
p I want to try treatments for a period of time in the hope of some improvement of my condition. I suggest
__________________________ as the period of time after which such treatment should be stopped if my condition
has not improved. Any agent or surrogate may specify the exact time period in consultation with my physician. I
understand that I still will receive treatment to relieve pain and make me comfortable. (OR)
p [YOU MAY WRITE HERE YOUR INSTRUCTIONS ABOUT YOUR CARE WHEN YOU ARE UNABLE
TO INTERACT WITH OTHERS AND ARE NOT EXPECTED TO RECOVER THIS ABILITY. THIS
INCLUDES SPECIFIC INSTRUCTIONS ABOUT TREATMENTS YOU DO WANT, IF MEDICALLY
APPROPRIATE, OR DO NOT WANT. IT IS IMPORTANT THAT YOUR INSTRUCTIONS HERE DO
NOT CONFLICT WITH OTHER INSTRUCTIONS YOU HAVE GIVEN IN THIS ADVANCE DIRECTIVE.]
______________________________________________________________________________________________________
______________________________________________________________________________________________________
—page 3 of 4—
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