Advance Health Care Directive Form

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A
H
C
D
DVANCE
EALTH
ARE
IRECTIVE FORM
Date:
Your Name:
Last
First
Middle initial
Street Address
City
State
Zip
Part 1: INDIVIDUAL INSTRUCTIONS FOR HEALTH CARE
The following statements only apply
• if I am close to death and life support would only postpone the moment of my death OR
• if I am in an unconscious state such as an irreversible coma or a persistent vegetative state and it is unlikely that I will ever
become conscious OR
• if I have brain damage or a brain disease that makes me permanently unable to make and communicate health-care deci-
sions about myself.
(INITIAL ONLY ONE (1) CHOICE IN EACH SECTION and CROSS OUT ALL THAT DO NOT APPLY.)
A. C
HOICE TO PROLONG OR NOT TO PROLONG LIFE
____ YES, I do want to have my life prolonged as long as possible within the limits of generally accepted health-care
standards that apply to my condition.
OR
____ NO, I do not want my life prolonged.
B. A
N
H
(
)
RTIFICIAL
UTRITION AND
YDRATION
FOOD AND FLUIDS
BY TUBE INTO STOMACH OR VEIN
____ YES, I do want artificial nutrition and hydration.
OR
____ NO, I do not want artificial nutrition and hydration.
C. R
P
ELIEF FROM
AIN
____ YES, I do want treatment to relieve my pain or discomfort.
OR
____ NO, I do not want treatment to relieve my pain or discomfort.
D. E
,
,
(
)
THICAL
RELIGIOUS
OR SPIRITUAL INSTRUCTIONS
OPTIONAL
Is there a church, temple, spiritual group or a special person from whom you wish to receive spiritual care?
Name:
Phone
Street Address
City
State
Zip
E.
,
?
____ YES
____ NO
DO YOU WANT HOSPICE CARE
IF APPROPRIATE
(Hospice provides physical, psychosocial, emotional, and spiritual support and counseling for the patient and his/her family.
Hospice is available in home, hospital, hospice-unit, and nursing home settings.)
F. P
RIMARY CARE PHYSICIAN
Name:
Phone
G. O
W
:
THER
ISHES
If you do not agree with any of the choices above or wish to add other instructions, including body and organ donation,
you may add pages. If you are or could become pregnant, consult your doctor, and consider adding special instructions
suspending or adding provisions. Remember to sign, date, witness or notarize additional pages. File a copy with:
Doctor copy
Family Copy
Agent Copy

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