Georgia Advance Directive For Health Care (Page 9 of 14) in pdf

7. Treatment Preferences

State your treatment preference by initialing (A), (B), or (C). If you choose (C), state your additional treat-

ment preferences by initialing one or more of the statements following (C). You may provide additional

instructions about your treatment preferences in the next section. You will be provided with comfort care,

including pain relief, but you may also want to state your specific preferences regarding pain relief in the

next section.

If I am in any condition that I initialed in Section (6) above and I can no longer communicate my treatment

preferences after reasonable and appropriate efforts have been made to communicate with me about my

treatment preferences, then:

A. _______ Try to extend my life for as long as possible, using all medications, machines, or other medical

(Initials) procedures that in reasonable medical judgment could keep me alive. If I am unable to take nutrition

or fluids by mouth, then I want to receive nutrition or fluids by tube or other medical means.

B. _______ Allow my natural death to occur. I do not want any medications, machines, or other medical

(Initials) procedures that in reasonable medical judgment could keep me alive but cannot cure me. I do

not want to receive nutrition or fluids by tube or other medical means except as needed to provide

pain medication.

C. _______ I do not want any medications, machines, or other medical procedures that in reasonable

(Initials) medical judgment could keep me alive but cannot cure me, except as follows:

Initial each statement that you want to apply to option C.

______ If I am unable to take nutrition by mouth, I want to receive nutrition by tube or other medical means.

(Initials)

______ If I am unable to take fluids by mouth, I want to receive fluids by tube or other medical means.

(Initials)

______ If I need assistance to breathe, I want to have a ventilator used.

(Initials)

______ If my heart or pulse has stopped, I want to have cardiopulmonary resuscitation (CPR) used.

(Initials)

8. Additional Statements

This section is optional. PART TWO will be effective even if this section is left blank. This section allows you to

state additional treatment preferences, to provide additional guidance to your Health Care Agent (if you

have selected a Health Care Agent in PART ONE), or to provide information about your personal and

religious values about your medical treatment. For example, you may want to state your treatment

preferences regarding medications to fight infection, surgery, amputation, blood transfusion, or kidney

dialysis. Understanding that you cannot foresee everything that could happen to you after you can no longer

communicate your treatment preferences, you may want to provide guidance to your Health Care Agent (if

you have selected a Health Care Agent in PART ONE) about following your treatment preferences. You may

want to state your specific preferences regarding pain relief.

Georgia Advance Directive For Health Care Page 9