2007 Advanced Directive Template (Page 3 of 5) in pdf

2007 Advanced Directive Template Page 3

Advanced Directive

Artificial nutrition and hydration

______

I do not want artificial nutrition and hydration started if they would be the main

treatments keeping me alive. If artificial nutrition and hydration are started, I want

them stopped.

______

I want artificial nutrition and hydration even if they are the main treatments

keeping me alive.

______

Other wishes

Comfort care

______

I want to be kept as comfortable and free of pain as possible, even if such care

prolongs my dying or shortens my life.

______

Other wishes

B. These are my wishes if I am ever in a persistent vegetative state.

Life-sustaining treatments

______

I do not want life-sustaining treatment (including CPR) started. If life-sustaining

treatments are started, I want them stopped.

______

I want the life-sustaining treatments that my doctors think are best for me.

______

Other wishes

Artificial nutrition and hydration

______

I do not want artificial nutrition and hydration started if they would be the main

treatments keeping me alive. If artificial nutrition and hydration are started, I want

them stopped.

______

I want artificial nutrition and hydration even if they are the main treatments

keeping me alive.

______

Other wishes

Created: 09/20/2007

Pinnacle Family Medicine, P.L.C.

page 3 of 5

2007 Advanced Directive Template Page 3