Advance Directive Medical Form printable pdf download

Advance Directive

I, ______________________________________, being of sound mind, willfully and

voluntarily make this directive to be followed if I become unable to participate in

decisions regarding medical care.

If I should be in a terminal condition, in a permanent state of unconsciousness or suffer

from irreversible brain damage with no hope of significant recovery, I direct my

attending physician to withhold or withdraw life-sustaining treatment that only prolongs

the process of my dying. I direct that treatment be limited to measures to keep me

comfortable and to relieve pain.

In addition, if I am in the condition described above, I feel strongly about the following

forms of treatment:

I do _____ do not _____ want cardiac resuscitation (CPR, chest compressions, electrical shock to

heart).

I do _____ do not _____ want to be put on a breathing machine (ventilator).

I do _____ do not _____ want transfusion of blood or blood products.

I do _____ do not _____ want surgery or invasive tests.

I do _____ do not _____ want dialysis (machine to replace kidney function).

I do _____ do not _____ want antibiotics (to fight infections).

I do _____ do not _____ want tube feeding or intravenous nutrition (food) or hydration (water).

I realize that if I do not specifically indicate my preference regarding any forms of

treatment listed above, I may receive that form of treatment. I also realize that illness

may take many forms and that it is impossible to predict every circumstance. My

physicians will try to follow the letter and spirit of my wishes if they are known.

Other instructions – Proxy Clause: (Check one)

I do _____ do not _____ want another person to make medical decisions on my behalf if

I am unable to communicate my instructions as outlined above. I have discussed (or will

discuss) my feelings with this person. I give my proxy permission to access my medical

records and allow my physician to discuss my health information with my proxy:

Proxy Name: _________________________ Address: __________________________

Phone: _____________________________

Substitute (If the first proxy is unable to serve): ________________________________

Address: ____________________________ Phone: _____________________________

Patient’s Signature: _____________________________Date of directive: __________

(Sign in the presence of two witnesses at least 18 years old.)

Witness: _____________________________ Address: ___________________________

Version 12/9/04 KB

Advance Directive Medical Form