Advance Directives And Living Wills (Page 3 of 4) in pdf

NOTICE OF POLICY REGARDING ADVANCE DIRECTIVES

Physicians’ Surgery Center requires that the following notice be read and signed by each patient prior to the scheduled

procedure in order to be in compliance with the Self-Directed Act (PSDA) State law and the rules regarding Advance

Directives. Advance Directives are statements that indicate the type of medical treatment wanted or not wanted in the

event an individual is unable to make those determinations and who is authorized to make those decisions. The Advance

Directives are made and witnessed prior to serious illness or injury. Physicians’ Surgery Center will copy Advance

Directives presented by the patient upon admission and place the document on the medical record.

There are many types of Advance Directives but the two most common forms are:

Living Wills

These generally state the type of medical care an individual wants or does not want if he/she becomes unable to make

his/her own decisions.

Durable Power of Attorney for Health Care

This is a signed, dated and witnessed paper naming another person as an individual’s agent or proxy to make

medical decisions for that individual if he/she should become unable to make his/her own decisions.

In the ambulatory care setting, if a patient should suffer a cardiac or respiratory arrest or other life threatening situation, the

signed consent implies consent for resuscitation and transfer to a higher level of care. Therefore, in accordance with federal

and state law, Physicians’ Surgery Center will notify the patient that it will not honor previously signed Advance Directives

for any patient. However, a copy of the Advance Directive, if presented by the patient, will be placed on the medical record

and forwarded to the facility receiving the patient for emergent care in the event of an emergency transfer to that facility. If

the patient disagrees with this issue, it must be addressed with the patient’s physician prior to signing this form.

[ ]

I understand that I am not required to have an Advance Directive in order to receive medical treatment in

this health care facility.

[ ]

I have executed an Advance Directive

[ ]

I have not executed an Advance Directive

I have read and fully understand the information presented in this release form.

_____________________________

Patient’s Signature

Witness to patient’s signature

Date: _________________________

If patient is unable to sign or is a minor, please sign below:

_____________________________

______________________________

Closest Relative or Legal Guardian’s Signature

Witness to Relative/Guardian’s Signature

Date: ___________________________

Date: ____________________________

Advance Directives And Living Wills Page 3