Form Fr-2090-Mwhc - Virginia Advance Medical Directive (Page 7 of 7) in pdf

SECTION 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 WISH TO 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.)

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.]

I do not want any treatment 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.

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)

[YOU MAY WRITE HERE YOUR OWN INSTRUCTIONS ABOUT YOUR CARE WHEN YOU ARE DYING, INCLUDING SPECIFIC INSTRUCTIONS ABOUT TREATMENTS

THAT YOU DO NOT 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.]:

____________________________________________________________________________________________________

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 awareness or ability even with medical treatment:

[CHECK ONLY 1 BOX IN THIS PART 2.]

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.

I want to try treatments for a period of time in the hope of some improvement of my condition. I suggest ________________

as the time after which such treatment should be stopped if my condition has not improved. The exact time period is at the

discretion of my agent or surrogate in consultation with my physician. I understand that I still will receive treatment to relieve

pain and make me comfortable. (OR)

[YOU MAY WRITE HERE YOUR OWN INSTRUCTIONS ABOUT YOUR CARE WHEN YOU ARE DYING, INCLUDING SPECIFIC INSTRUCTIONS ABOUT TREATMENTS

THAT YOU DO NOT 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.]:

________________________________________________________________________________________________________

3. I provide the following other instructions concerning my health care:

[YOU MAY WRITE HERE YOUR OWN INSTRUCTIONS ABOUT YOUR CARE WHEN YOU ARE DYING, INCLUDING SPECIFIC INSTRUCTIONS ABOUT TREATMENTS THAT

YOU DO NOT 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.]:

________________________________________________________________________________________________________

AFFIRMATION AND RIGHT TO REVOKE:

By signing below, I indicate that I understand this document and that I am willingly and

voluntarily executing it. I also understand that I may revoke all or any part of it at any time as provided by law.

________________________________________________________________________________________________________________________

Date

Signature of Declarant

The declarant signed the foregoing advance directive in my presence.

[TWO ADULT WITNESSES NEEDED]

___________________________________________________________________________

________________________________________________________________________

Witness Signature

Witness Printed

___________________________________________________________________________

________________________________________________________________________

Witness Signature

Witness Printed

This form satisfies the requirements of Virginia’s Health Care Decisions Act. If you have legal questions about this form or would like to develop a

different form to meet your particular needs, you should talk to an attorney. It is your responsibility to provide a copy of your advance medical

directive to your treating physician. You also should provide copies to your agent,, close relatives and/or friends. This form is provided by the

Virginia Hospital & Healthcare Association as a service to its members and the public. (March 2010, )

*CH0015*

Virginia Advance Directive for Health Care – Basic Form

FR-2090-MWHC 9/2010

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Form Fr-2090-Mwhc - Virginia Advance Medical Directive Page 7

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