Georgia Advance Directive For Health Care (Page 4 of 6) in pdf

PART TWO—Treatment Preferences

PART TWO will be effective only if you are unable to communicate your treatment preferences after reasonable and

appropriate efforts have been made to communicate with you about your treatment preferences. PART TWO will be effective

even if PART ONE is not completed. If you have not selected a health care agent in PART ONE, or if your health care agent is

not available, then PART TWO will provide your physician and other health care providers with your treatment preferences. If

you have selected a health care agent in PART ONE, then your health care agent will have the authority to make all health

care decisions for you regarding matters covered by PART TWO. Your health care agent will be guided by your treatment

preferences and other factors described in Section (4) of PART ONE.

6. Conditions

PART TWO will be effective if I am in any of the following conditions:

Initial each condition in which you want PART TWO to be effective.

_________ (Initials) A terminal condition, which means I have an incurable or irreversible condition that will result

in my death in a relatively short period of time.

_________ (Initials) A state of permanent unconsciousness, which means I am in an incurable or irreversible

condition in which I am not aware of myself or my environment and I show no behavioral

response to my environment.

My condition will be determined in writing after personal examination by my attending physician and a second

physician in accordance with currently accepted medical standards.

7. Treatment Preferences

State your treatment preference by initialing (A), (B), or (C). If you choose (C), state your additional treatment preferences by

initialing one or more of the statements following (C). You may provide additional instructions about your treatment

preferences in the next section. You will be provided with comfort care, including pain relief, but you may also want to state

your specific preferences regarding pain relief in the next section.

If I am in any condition that I initialed in Section (6) above and I can no longer communicate my treatment preferences

after reasonable and appropriate efforts have been made to communicate with me about my treatment preferences,

then:

(A) _________ (Initials) Try to extend my life for as long as possible, using all medications, machines, or other

medical procedures that in reasonable medical judgment could keep me alive. If I am unable

to take nutrition or fluids by mouth, then I want to receive nutrition or fluids by tube or other

medical means.

(B) _________ (Initials) Allow my natural death to occur. I do not want any medications, machines, or other medical

procedures that in reasonable medical judgment could keep me alive but cannot cure me. I do

not want to receive nutrition or fluids by tube or other medical means except as needed to

provide pain medication.

medical judgment could keep me alive but cannot cure me, except as follows:

Initial each statement that you want to apply to option (C).

_________ (Initials) If I am unable to take nutrition by mouth, I want to receive nutrition by tube or other medical

means.

_________ (Initials) If I am unable to take fluids by mouth, I want to receive fluids by tube or other medical means.

_________ (Initials) If I need assistance to breathe, I want to have a ventilator used.

_________ (Initials) If my heart or pulse has stopped, I want to have cardiopulmonary resuscitation (CPR) used.

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