Fillable Advance Directive (Page 3 of 7) in pdf

Advance Directive Page 3

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PART B: APPOINTMENT OF HEALH CARE REPRESENTATIVE (CONTINUED)

1. Limits.

Special Conditions or Instructions: _________________________________________________

______________________________________________________________________________

INITIAL IF THIS APPLIES:

_______ I have executed a Health Care Instruction or Directive to Physicians. My

representative is to honor it.

2. Life Support.

“Life support” refers to any medical means for maintaining life, including procedures, devices and

medications. If you refuse life support, you will still get routine measures to keep you clean and

comfortable.

INITIAL IF THIS APPLIES:

_______ My representative MAY decide about life support for me. (If you don’t initial this

space, then your representative MAY NOT decide about life support.)

3. Tube Feeding.

One sort of life support is food and water supplied artificially by medical device, known as tube feeding.

INITIAL IF THIS APPLIES:

_______ My representative MAY decide about tube feeding for me. (If you don’t initial this

space, then your representative MAY NOT decide about tube feeding.)

_______________________________

(Date)

SIGN HERE TO APPOINT A HEALTH CARE REPRESENTATIVE

__________________________________________________

(Signature of person making appointment)

Advance Directive Page 3

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