Advanced Directive Form (Page 2 of 4) in pdf

You are welcome to make copies of the form and this cover sheet, but only for the personal use

of you or your loved ones and not for any commercial purpose.

Please note the following:

1) Although only one decision-maker (“agent”) needs to be identified in the document, there is

space for two additional back-up decision-makers ("alternate agents") to be identified.

Identifying at least one alternate agent is a particularly wise idea.

2) The signatures of the agent and alternate agents at the end of the document are not required in

most states.

However, obtaining them assures that all identified decision-makers get the

opportunity to read the advance directive—and hopefully to discuss it with you as well—so that

they are in a good position to honor your wishes should the need arise.

3) Keep a copy of your completed advance directive in an easily-accessible place in your home

and advise people particularly close to you where that location is. The agent and alternate agents

named in the form should also receive signed originals of the form, as should your physician, and

your attorney if you have one. Keep a list of who has these originals, so that you know whom to

contact if you re-do your form. The form specifies that photocopies are not authoritative, so that

if you update and replace the original forms you can be sure that out-of-date photocopies will not

create confusion later regarding your latest wishes.

4) Any words can be deleted from the guidelines regarding your care on page 1 of the form

simply by crossing them off. Wherever words are deleted, the person producing the advance

directive (the “Principal”) needs to sign his or her initials beside the material deleted. As

indicated at the beginning of the Guidelines section, you can delete all guidelines and simply

appoint an agent.

5) Anything can be added to the guidelines on page 1 as well. To add material, record your

additional instructions or other comments on pages separate from the form, attach those pages to

the form, and write the number of pages being added in the designated space near the beginning

of the Guidelines section. If there are no additional pages, write “0” in that box.

6) The form allows ending treatment if certain medical criteria are clearly met according to one

or more physicians who have personally examined you. Advise your agent that while a physician

well known and trusted by you or the agent may be sufficient to make any medical

determinations involved, the agent should obtain further medical opinion if there is any question

about the physician’s competence or objectivity.

7) There are two boxes near the bottom of page 1 that allow you to specify your wishes regarding

artificial nutrition and hydration (forms of food and water administered through tubes or IV lines

for those unable to swallow well). Some feel that they are mandatory even when other life-

sustaining technological interventions are withheld or withdrawn. However, others consider the

justification of artificial food and water—like that of artificial air (provided through a ventilator)

and other life-sustaining interventions—to depend on whether they can truly enable life to

continue or they essentially add a burden to an imminent and unavoidable dying process. See the

BioBasics End of Life Decisions book, question #22.

You are encouraged to add, on additional pages, anything you like concerning your faith

convictions, your personal values, and/or your health care goals in order to give your agent as

complete a picture of your priorities as possible. Your views concerning other issues covered in

the End of Life Decisions book can also be included here—such as the care you want if you

become disabled, demented, permanently unconscious, or in severe pain. Of course, some or all

of that information can be conveyed orally instead if you prefer.

Printed 2-14-04

Advanced Directive Form Page 2

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