Georgia Advanced Directives For Health Care Form Page 7
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9(Initials) If my heart or pulse has stopped
I want to have cardiopulaonary
resuscitation (CpR) used.
(8) ADDTTTONAL STATEMENTS
fThis section is optional' PART TWo will be effective even
dthis section is left btank. This section
allows you to state additional treatment pnf"iiour,
to provide additional guidance to your health
care agent ('fyou have selected a health caie agmt in P,4RT
oNE), or to provide information about
your personal and religious values about your medical
treatment. For example, you mry want to
state your treatment preferences regarding medications
to fight infection, surgery, amputation,
blood transfusion, or kidney dialysis. tlndJrstanding that yau
cannotforesee everything that could
happen to you arter you can no longer communicate your,treatment
preferenees, you mqt want to
provide guidance to your heakh eare agent (tfyou have
selectea a heitti care agent in pART oNE)
about following ylu:-treatment preferences. You may
want to state your specific preferences
r e garding p ain r e li ef.J
(e) rN cAsE oF PREGNANCY
?ARr rwowill
be effective event if this section is teft btank)
I understand that oogo Georgia law, PART Two generally
will have no force and effect if I am
pregnant unless the fetus is not viable and I indicut"-by
initialingbelow that I want pART TWo to
be calried out-
(Inifials) I want PART Two to be carried out
if my fetns is not viable.
PART THREE: GUARDIANSHIP
(10) GUARDTANSHTP
IPART THREE is optionaL This advance directivefor health care will
be effective even if pART
THREE is left btank. If you wish to nominate a person
r;;;;;;;
sr;";;"
in the event a court
decides that a guTfan
should be appointed, impiete pAR:r rungz.
a court wiII appoint a
guardianfor you ifthe courtfinds thaiyou are not
able to make significant responstble decisionfor
yourself regarding yo-ur personal suwort, safety,
or welfare. 2'court wilt appoint the person
nominated by you if the courtfinds th.at tne appoiitment
will serve your best interest and welfare,
tfyou have
lelected
a health care agent tn pinr
oxg, you may (but are not required to) nominate
Page 7 of9 pagds.
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