Advance Directive Template (Page 2 of 4) in pdf

Persistent Vegetative State: When a person is unconscious with no hope of regaining consciousness even

with medical treatment. The body may move and eyes may be open but as far as anyone can tell, the

person can’t think or respond.

Terminal Condition: An on-going condition caused by injury or illness that has no cure and from which

doctors expect the person to die even with medical treatment. Life-sustaining treatments will only prolong

a person’s dying if the person is suffering from a terminal condition.

D.C., Maryland and Virginia

ADVANCE DIRECTIVE

Your Durable Power of Attorney for Health Care,

Living Will and Other Wishes

, ____________________

document as a directive regarding my medical care.

write this

Put the initials of your name by the choices you want.

PART 1. MY DURABLE POWER OF ATTORNEY FOR HEALTH CARE

______I appoint this person to make decisions about my medical care if there ever comes

a time when I cannot make those decisions myself:

NAME_________________________________PHONE: HOME __________________WORK______________________________

ADDRESS__________________________________________________________________________________________________

____________________________________________________________________________________________________________

If the person above can’t or will not make decisions for me, I appoint this person:

NAME_________________________________PHONE :HOME___________________WORK______________________________

ADDRESS__________________________________________________________________________________________________

____________________________________________________________________________________________________________

_____I have not appointed anyone to make health care decisions for me in this or any

Advance Directive Template Page 2