Advance Directive For Health Care (Page 2 of 6) in pdf

Advance Directive For Health Care Page 2

Artificially provided food and hydration (Food and water through a tube or an

IV) - I understand that if I am terminally ill or injured I may need to be given

food and water through a tube or an IV to keep me alive if I can no longer chew

or swallow on my own or with someone helping me.

Place your initials by either "yes" or "no":

I want to have food and water provided through a tube or an IV if I am

terminally ill or injured. ____ Yes ____ No

IF I BECOME PERMANENTLY UNCONSCIOUS:

Permanent unconsciousness is when my doctor and another doctor agree that

within a reasonable degree of medical certainty I can no longer think, feel

anything, knowingly move, or be aware of being alive. They believe this

condition will last indefinitely without hope for improvement and have watched

me long enough to make that decision. I understand that at least one of these

doctors must be qualified to make such a diagnosis.

Life sustaining treatment - Life sustaining treatment includes drugs, machines,

or other medical procedures that would keep me alive but would not cure me. I

know that even if I choose not to have life sustaining treatment, I will still get

medicines and treatments that ease my pain and keep me comfortable.

Place your initials by either "yes" or "no":

I want to have life-sustaining treatment if I am permanently unconscious.

____ Yes ____ No

Artificially provided food and hydration (Food and water through a tube or an

IV) - I understand that if I become permanently unconscious, I may need to be

given food and water through a tube or an IV to keep me alive if I can no

longer chew or swallow on my own or with someone helping me.

Place your initials by either "yes" or "no":

I want to have food and water provided through a tube or an IV if I am

permanently unconscious. ____ Yes ____ No

OTHER DIRECTIONS:

Advance Directive For Health Care Page 2