Directive To Physicians - Healthcare Partners printable pdf download

Directive To Physicians - Healthcare Partners

ADVANCE DIRECTIVE

I have been provided

I have declined

information regarding my advanced directives.

(Please Check One Box)

__________________________________________

_______ - _____ - _______

(Please Print Full Name)

(Social Security Number)

Signature : _________________________________ Date: ___________________________

(Patient or Patient Representative)

Relationship of Patient Representative (If applicable): ________________________________

DIRECTIVE TO PHYSICIANS

If I should have an incurable and irreversible condition that, without the administration of life-

sustaining treatment, will, in the opinion of my attending physician, cause my death within a

relatively short time, and I am no longer able to make decisions regarding my medical

treatment, I direct my attending physician, pursuant to the Nevada Uniform Act on Rights of the

Terminally Ill, to withhold or withdraw treatment that only prolongs the process of dying and is

not necessary for my comfort or to alleviate pain.

•

If you wish to include this statement in this declaration, you must INITIAL the statement in the

box provided:

Withholding or withdrawal of artificial nutrition and hydration may result in

death by starvation or dehydration. Initial this box if you want to receive or

continue receiving artificial nutrition and hydration by way of gastro-

intestinal tract after all other treatment is withheld pursuant to this

[ _______________]

declaration.

Signed this __________________________day of ___________________________, 201 ___

Signature ___________________________ PRINT NAME ____________________________

Address ____________________________________________________________________

The declaring voluntarily signed this writing in my presence.

Witness ____________________________

State of Nevada County of ________________

Address ____________________________

This instrument was acknowledged before me

____________________________

on _________ by____________________.

___________________

(

Signature of notarial officer)

(Feb 2009)

Directive To Physicians - Healthcare Partners