2007 Advanced Directive Template

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Advanced Directive
This form is a combined durable power of attorney for health care and a living will (in some jurisdictions). With
this form, you can name someone to make medical decisions for you if in the future you're unable to make those
decisions yourself. You can also say what medical treatments you want and what medical treatments you don't
want if in the future you're unable to make your wishes known.
Instructions
Read each section carefully. Before you fill out the form talk to the person you want to name, to make sure that
he/she understands your wishes and is willing to take the responsibility. Write your initials in the blank spaces
before the choices you want to make. Write your initials only beside the choices you want under Parts 1, 2 and 3 of
this form. Your advance directive should be valid for whatever part(s) you fill in, as long as it is properly signed.
Add any special instructions in the blank spaces provided. You can write additional comments on a separate sheet
of paper, but you should write on this form that there are additional pages to your advance directive. Sign the form
and have it witnessed. Give copies to your doctor, your nurse, the person you name to make your medical
decisions for you, people in your family and anyone else who might be involved in your care. Discuss your
advance directive with them.
Understand that you may change or cancel this document at any time.
Definitions to Know
Advance directive--A written document (form) that tells what a person wants or doesn't want if he/she in the
future can't make his/her wishes known about medical treatment.
Artificial nutrition and hydration--When food and water are fed to a person through a tube.
Autopsy--An examination done on a dead body to find the cause of death.
Comfort care--Care that helps to keep a person comfortable but doesn't make him/her get well. Bathing, turning
and keeping a person's lips moist are types of comfort care.
CPR (cardiopulmonary resuscitation)--Treatment to try to restart a person's breathing or heartbeat. CPR may be
done by pushing on the chest, by putting a tube down the throat or by other treatment.
Durable power of attorney for health care--An advance directive that names someone to make medical
decisions for a person if in the future he/she can't make his/her own medical decisions.
Life-sustaining treatment--Any medical treatment that is used to keep a person from dying. A breathing machine,
CPR, and artificial nutrition and hydration are examples of life-sustaining treatments.
Living will--An advance directive that tells what medical treatment a person does or doesn't want if he/she is not
able to make his/her wishes known.
Organ and tissue donation--When a person permits his/her organs (such as the eyes or kidneys) and other parts
of the body (such as the skin) to be removed after death to be transplanted for use by another person or to be
used for experimental purposes.
Persistent vegetative state--When a person is unconscious with no hope of regaining consciousness even with
medical treatment. The body may move and the eyes may be open, but as far as anyone can tell, the person can't
think or respond.
Terminal condition--An ongoing condition caused by injury or illness that has no cure and from which doctors
expect the person to die even with medical treatment. Life-sustaining treatments will only prolong the dying
process if the person is suffering from a terminal condition.
Created: 09/20/2007
Pinnacle Family Medicine, P.L.C.
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