Advanced Directive Form (Page 3 of 4) in pdf

Advance Directive for Health Care

(only originals are authoritative – photocopies are for informational purposes only)

(read accompanying 2-page Introduction before completing this form)

I, ________________________________________________________________________________________

(Name of Person Making This Advance Directive: the Principal)

hereby appoint: ____________________________________________________________________________

(Name of Person Empowered to Make Decisions for the Principal: the Agent)

as my “agent” to act for me and in my name (in any way I could act in person) should I become mentally

incompetent to make decisions concerning my personal care, medical treatment, hospitalization, and health care

and to require, withhold, or withdraw any type of medical treatment or procedure, even though my death may

ensue. My agent shall have the same access to my medical records that I have, including the right to disclose

the contents to others. My agent shall also have the full power to make a disposition of any part or all of my

body for medical purposes, authorize an autopsy and direct the disposition of my remains.

__________________________________________________________________________________________

(Address of Agent)

______________________________

________________________________

(Agent’s Daytime Phone Number)

(Agent’s Evening Phone Number)

Guidelines Regarding My Care

Initial here _____ and cross off the rest of this page if you prefer not to include any guidelines

Write here _____ the number of pages of further instructions added to this two-page form

The guidelines on this page (or on any attachments to this document) are to be followed except where my agent

deems that following them would result in an action contrary to my wishes.

• I want any medical or other procedures deemed necessary by my attending physician to

provide me with comfort or respect care.

• I want my life to be prolonged, and I want life-sustaining treatment to be provided or

continued, except as noted below.

Ending Treatment

If it has been clearly determined by one or more physicians who have personally examined me

that my death is imminent even with death-delaying procedures:

• I direct that such procedures that would be burdensome by prolonging the dying process be

withheld or withdrawn.

• Under no circumstances do I want assisted suicide, euthanasia, or any other action done with

the intention of ending my life.

Food and Fluids

As long as I can swallow safely, I want to be provided with food and fluids. If I am unable to swallow sufficient

food and fluids, an “x” in the box beside either statement below clarifies how I want artificial nutrition and

hydration (e.g., feeding tube or IV line) to be handled.

Artificial nutrition and hydration should be considered mandatory even when other interventions are

withheld or withdrawn; OR

Artificial nutrition and hydration should be subject to the same guidelines as other life-sustaining

technological interventions.

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