Designation Of Patient Advocate Form And Directions For Durable Power Of Attorney For Health Care Form Page 2
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4You may list specific care and treatment you do or do not want. Otherwise, your general instructions will stand for your wishes.
1.
General Instructions
My Patient Advocate shall have the authority to make all decisions and to take all actions regarding my care, custody and medical
treatment including, but not limited, to the following:
a.
Have access to, obtain copies of and authorize release of my medical and other personal information.
b.
Employ and discharge physicians, nurses, therapists and any other health care providers and arrange to pay them
reasonable compensation.
c.
Consent to, refuse or withdraw for me any medical care; diagnostic, surgical or therapeutic procedure; or other treatment of any type or
nature, including life-sustaining treatments. I understand that life-sustaining treatment includes, but is not limited to, breathing with the
use of a machine and receiving food, water and other liquids through tubes. I also understand that these decisions could or would allow
me to die. I have listed below any specific instructions I have related to life-sustaining treatments.
2.
Specific Instructions
My Patient Advocate is to be guided in making medical decisions for me by what I have told him/her about my personal preferences
regarding my care. Some of my preferences are recorded below and on the following page.
a.
Specific Instructions Regarding Care I Do Want.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
b.
Specific Instructions Regarding Care I Do Not Want.
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
You do not have to choose one of the specific instructions about life-sustaining treatment in this section. But if you do,
sign only one instruction.
You should discuss these choices with your doctor.
c.
Specific Instructions Regarding Life-Sustaining Treatment.
I understand that I do not have to choose one of the instructions regarding life-sustaining treatment listed below. If I choose one,
I will sign below my choice.
Choice 1: I do not want my life to be prolonged by providing or continuing life-sustaining treatment if any of the following medical conditions exist.
I am in an irreversible coma or persistent vegetative state.
I am terminally ill and life-sustaining procedures would serve only to artificially delay my death.
Under any circumstances where my medical condition is such that the burdens of the treatment outweigh the expected benefits.
In weighing the burdens and benefits of treatment, I want my Patient Advocate to consider the relief of suffering and the quality
of my life as well as the extent of possibly prolonging my life.
I understand that this decision could or would allow me to die.
_______________________________________________________
If this statement reflects your desires, sign here:
Choice 2: I want my life to be prolonged by life-sustaining treatment unless I am in a coma or vegetative state which my doctor reasonably
believes to be irreversible. Once my doctor has reasonably concluded that I will remain unconscious for the rest of my life, I do not want
life-sustaining treatment to be provided or continued. I understand that this decision could or would allow me to die.
If this statement reflects your desires, sign here:
_______________________________________________________
Choice 3: I want my life to be prolonged to the greatest extent possible consistent with sound medical practice without regard to my condition,
the chances I have for recovery or the cost of my care and I direct life-sustaining treatment be provided in order to prolong my life.
If this statement reflects your desires, sign here:
_______________________________________________________
d. Specific Instructions Regarding Medical Examinations
My religious beliefs prohibit a medical examination to determine whether I am unable to participate in making medical treatment
decisions. I desire this determination to be made in the following manner:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
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