Vermont Advance Directive For Health Care (Page 4 of 8) in pdf

ADVANCE DIRECTIVE, PAGE 2

NAME ____________________________________________________________ DOB _____________________DATE ________________

Part Two: Treatment Wishes

Please express your preferences that follow by initialing or checking the statements. You may initial more

than one choice. Draw a line through any statement you do not agree with. If you do nothing, your agent or

others such as family members and doctors treating you will assume you want them to decide for you. If you

do not state a preference for withholding or withdrawing artiﬁ cial food and hydration (tube feeding),

your agent may not have authority to withhold or withdraw it, without a court order, if you are being

treated in a New York or New Hampshire hospital.

_____ A. My choice is to limit treatment.

(Initial or check those statements below that you agree with.)

____ 1. I do not want to be kept alive if I am so sick that I will die within a relatively short time

(I cannot get better and have only weeks, days, or hours left to live).

____ 2. I do not want to be kept alive if I become unconscious or unaware of my surroundings

and most doctors agree that I will never regain consciousness.

____ 3. I do not want to be kept alive if I become unable to think or act for myself (and won’t

get better).

____ 4. I do not want to be kept alive if the likely risks and burdens of treatment would

outweigh the expected beneﬁ ts. (Specify what is most important for you.)

_____ 5. If it is possible that I might recover with treatment and more time is needed to

determine if I can get better or not, I wish my medical team to start the necessary

treatments to keep me alive. If, over time, these treatments do not improve my chances

of living or my physical condition, I wish to have life-sustaining treatment stopped.

_____ 6. If I am also unable to swallow enough food and water to stay alive, I do want food and

water to be given to me by vein or by feeding tube; (or)

_____ 7. If I am also unable to swallow enough food and water to stay alive, I do not want food

do not want food

do not

and water to be given to me by vein or feeding tube; however, I will accept medication

for pain and agitation via an IV line.

_____ 8. Other speciﬁ c instructions are as follows:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

_____ B. My choice is to sustain life. I want to be kept alive as long as possible

through any means possible regardless of my condition or awareness.