Vermont Advance Directive For Health Care Page 5

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ADVANCE DIRECTIVE, PAGE 3
NAME ____________________________________________________________ DOB _____________________DATE ________________
Specifi c Care Wishes Near the End of My Life
_____ If it becomes clear to my doctor, my agent, and those caring for me that I am dying, I want
palliative care for my pain, worries, nausea, and other conditions that bother me. I want suffi cient
pain medication even though it may have the
pain medication even though it may have the
pain medication
unintended eff ect of hastening my death.
unintended eff ect of hastening my death.
unintended eff ect
_____ I want hospice care when I am dying, if possible and appropriate.
_____ I prefer to die at home, if this is possible.
Spiritual and Other Care Concerns
I am of the ______________________________ faith. Below is the contact information (if known).
Church, synagogue, or worship center:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ADDRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
LEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . TEL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other people to notify if I have a life-threatening illness:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Th e following items or music or readings would be a comfort to me:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Part Three: Instructions about Organ and Tissue Donation
I wish to make known my decisions regarding organ and tissue donation and whole body donation so that
my instructions will be followed after my death.
I consent to donate the following organs and tissues:
____ any needed organs (such as heart, lung, kidney, liver)
____ any needed tissue (such as cornea, bone, and skin)
I do not wish to donate the following organs and tissues:
not wish to donate the following organs and tissues:
not
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
____ I wish to make no decision about organ and tissue donation at this time.
no decision about organ and tissue donation at this time.
no decision
____ I do not wish to be an organ and tissue donor.
not wish to be an organ and tissue donor.
not
____ I desire to donate my body to research or educational program (Note: you will have to make your
own arrangements through a medical school or other program.)
____ If an autopsy is suggested for any reason, I give my permission to have it done.
autopsy is suggested for any reason, I give my permission to have it done.
autopsy

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