Form Ph-4194 - Advance Care Plan
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2Tennessee Department of Health
Division of Health Licensure and Regulation
Office of Health Care Facilities
227 French Landing, Suite 501
Heritage Place Metrocenter
Nashville, TN 37243
Telephone (615) 741-7221
Fax (615) 253-8798
ADVANCE CARE PLAN
(Tennessee)
I, ____________________________________, hereby give these advance instructions on how I want to be treated by my doctors and other
health care providers when I can no longer make those treatment decisions myself.
Agent: I want the following person to make health care decisions for me. This includes any health care decision I could have made for
myself if able, except that my agent must follow my instructions below:
Name: ___________________________________ Phone #: (___ )___________ _ Relation: _________________________________
Address: _________________________________________________________________________________________________________
Alternate Agent: If the person named above is unable or unwilling to make health care decisions for me, I appoint as alternate the following
person to make health care decisions for me. This includes any health care decision I could have made for myself if able, except that my
agent must follow my instructions below:
Name: ___________________________________ Phone #: (__ _)_____________ Relation: _________________________________
Address: _________________________________________________________________________________________________________
My agent is also my personal representative for purposes of federal and state privacy laws, including HIPAA.
When Effective (mark one):
I give my agent permission to make health care decisions for me at any time, even if I have capacity to make decisions for myself.
I do not give such permission (this form applies only when I no longer have capacity).
Quality of Life: By marking “yes” below, I have indicated conditions I would be willing to live with if given adequate comfort care and pain
management. By marking “no” below, I have indicated conditions I would not be willing to live with (that to me would create an
unacceptable quality of life).
Permanent Unconscious Condition: I become totally unaware of people or surroundings with little chance of ever waking up
Yes
No
from the coma.
Permanent Confusion: I become unable to remember, understand, or make decisions. I do not recognize loved ones or
Yes
No
cannot have a clear conversation with them.
Dependent in all Activities of Daily Living: I am no longer able to talk or communicate clearly or move by myself. I depend
Yes
No
on others for feeding, bathing, dressing, and walking. Rehabilitation or any other restorative treatment will not help.
End-Stage Illnesses: I have an illness that has reached its final stages in spite of full treatment. Examples: Widespread cancer
Yes
No
that no longer responds to treatment; chronic and/or damaged heart and lungs, where oxygen is needed most of the time and
activities are limited due to the feeling of suffocation.
Treatment: If my quality of life becomes unacceptable to me (as indicated by one or more of the conditions marked “no” above) and my
condition is irreversible (that is, it will not improve), I direct that medically appropriate treatment be provided as follows. By marking “yes”
below, I have indicated treatment I want. By marking “no” below, I have indicated treatment I do not want.
CPR (Cardiopulmonary Resuscitation): To make the heart beat again and restore breathing after it has stopped. Usually this
Yes
No
involves electric shock, chest compressions, and breathing assistance.
Life Support / Other Artificial Support: Continuous use of breathing machine, IV fluids, medications, and other equipment
Yes
No
that helps the lungs, heart, kidneys, and other organs to continue to work.
Treatment of New Conditions: Use of surgery, blood transfusions, or antibiotics that will deal with a new condition but will
Yes
No
not help the main illness.
Tube feeding/IV fluids: Use of tubes to deliver food and water to a patient’s stomach or use of IV fluids into a vein, which
Yes
No
would include artificially delivered nutrition and hydration.
Please sign on page 2
Page 1 of 2
PH-4194
RDA- n/a
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Parent category: Medical