Georgia Advance Directive For Health Care (Page 8 of 14) in pdf

Georgia Advance Directive For Health Care Page 8

C. Final Disposition of Body

My Health Care Agent will have the power to make decisions about the final disposition of my body unless I

have initialed below.

_________ I want the following person to make decisions about the final disposition of my body:

(Initials)

Name: _______________________________________________________________________

Address: ______________________________________________________________________

Telephone Numbers: _____________________________________________________________

(Home, Work, and Mobile)

I wish for my body to be:

_________ Buried OR

_________ Cremated

(Initials)

Part Two: Treatment Preferences

PART TWO will be effective only if you are unable to communicate your treatment preferences after reason-

able and appropriate efforts have been made to communicate with you about your treatment preferences.

PART TWO will be effective even if PART ONE is not completed. If you have not selected a Health Care Agent

in PART ONE, or if your health care agent is not available, then PART TWO will provide your physician and

other health care providers with your treatment preferences. If you have selected a Health Care Agent in

PART ONE, then your Health Care Agent will have the authority to make all health care decisions for you

regarding matters covered by PART TWO. Your Health Care Agent will be guided by your treatment prefer-

ences and other factors described in Section (4) of PART ONE.

6. Conditions

PART TWO will be effective if I am in any of the following conditions:

Initial each condition in which you want PART TWO to be effective.

_________ A terminal condition, which means I have an incurable or irreversible condition that will result

(Initials)

in my death in a relatively short period of time.

_________ A state of permanent unconsciousness, which means I am in an incurable or irreversible

(Initials)

condition in which I am not aware of myself or my environment and I show no behavioral

response to my environment.

My condition will be determined in writing after personal examination by my attending physician and a second

physician in accordance with currently accepted medical standards.

Georgia Advance Directive For Health Care Page 8