2007 Advanced Directive Template (Page 4 of 5) in pdf

2007 Advanced Directive Template Page 4

Advanced Directive

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

C. Other directions

You have the right to be involved in all decisions about your medical care, even those not dealing with terminal

conditions or persistent vegetative states. If you have wishes not covered in other parts of this document, please

indicate them below.

PART 3. Other Wishes

A. Organ donation

I do not wish to donate any of my organs or tissues.

______

I want to donate all of my organs and tissues.

______

I only want to donate these organs and tissues:

______

Other wishes

______

B. Autopsy

I do not want an autopsy.

______

I agree to an autopsy if my doctors wish it.

______

Other wishes

______

C. Other statements about your medical care

If you wish to say more about any of the choices you have made or if you have any other statements to make

about your medical care, you may do so on a separate piece of paper. If you do so, put here the number of pages

you are adding: _________

Created: 09/20/2007

Pinnacle Family Medicine, P.L.C.

page 4 of 5

2007 Advanced Directive Template Page 4