Fillable Kentucky Living Will Directive And Health Care Form (Page 6 of 8) in pdf

Kentucky Living Will Directive And Health Care Form Page 6

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iving

iLL

irective anD

eaLth

are

urrogate

esignation of

_________________________________________

(PRINTED NAME)

___________________________

(DATE OF BIRTH)

My wishes regarding life-prolonging treatment and artificially provided nutrition and

hydration to be provided to me if I no longer have decisional capacity, have a terminal

condition, or become permanently unconscious have been indicated by checking and

initialing the appropriate lines below.

eaLth

are

urrogate

esignation

By checking and initialing the line below, I specifically:

_______ (check box and initial line, if you desire to name a surrogate)

Designate ___________________________ as my health care surrogate(s) to

make health care decisions for me in accordance with this directive when I no

longer have decisional capacity. If _______________________ refuses or is not

able to act for me, I designate __________________________ as my health

care surrogate(s).

Any prior designation is revoked.

iving

iLL

irective

If I do not designate a surrogate, the following are my directions to my attending physician.

If I have designated a surrogate, my surrogate shall comply with my wishes as indicated

below. By checking and initialing the lines below, I specifically:

Life Prolonging Treatment (check and initial only one)

_______ (check box and initial line, if you desire the option below)

Direct that treatment be withheld or withdrawn, and that I be permitted to die

naturally with only the administration of medication or the performance of any

medical treatment deemed necessary to alleviate pain.

_______ (check box and initial line, if you desire the option below)

DO NOT authorize that life-prolonging treatment be withheld or withdrawn.

Nourishment and/or Fluids (check and initial only one)

_______ (check box and initial line, if you desire the option below)

Authorize the withholding or withdrawal of artificially provided food, water, or

other artificially provided nourishment or fluids.

Kentucky Living Will Directive And Health Care Form Page 6

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