Fillable Advance Directive (Page 4 of 7) in pdf

Advance Directive Page 4

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PART C: HEALTH CARE INSTRUCTIONS

NOTE: In filling out these instructions, keep the following in mind:

• The term “as my physician recommends” means that you want your physician to try life

support if your physician believes it could be helpful and then discontinue it if it is not helping

your health condition or symptoms.

• “Life support” and “tube feeding” are defined in PART B above.

• If you refuse tube feeding, you should understand that malnutrition, dehydration and death

will probably result.

• You will get care for your comfort and cleanliness, no matter what choices you make.

• You may either give specific instructions by filling out Items 1 to 4 below, or you may use

the general instruction provided by Item 5.

Here are my desires about my health care if my doctor and another knowledgeable doctor confirm that

I am in a medical condition described below:

1. Close to Death. If I am close to death and life support would only postpone that moment of my

death:

A. INITIAL ONE:

_______ I want to receive tube feeding.

_______ I want tube feeding only as my physician recommends.

_______ I DO NOT WANT tube feeding.

B. INITIAL ONE:

_______ I want any other life support that may apply.

_______ I want life support only as my physician recommends.

_______ I want NO life support.

2. Permanently Unconscious. If I am unconscious and it is very unlikely that I will ever become

conscious again: