Advance Health Care Directive Form Page 3
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5ADVANCE HEALTH CARE DIRECTIVE FORM
PAGE 3 of 5
(1.6)
NOMINATION OF CONSERVATOR: If a conservator of my person needs to be appointed for me by a court, I
nominate the agent designated in this form. If that agent is not willing, able, or reasonably available to act as conservator, I
nominate the alternate agents whom I have named, in the order designated.
PART 2
INSTRUCTIONS FOR HEALTH CARE
If you fill out this part of the form, you may strike any wording you do not want.
(2.1)
END-OF-LIFE DECISIONS: I direct that my health care providers and others involved in my care provide, withhold,
or withdraw treatment in accordance with the choice I have marked below:
(a) Choice Not to Prolong Life
I do not want my life to be prolonged if (1) I have an incurable and irreversible condition that will result in my death
within a relatively short time, (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain
consciousness, or (3) the likely risks and burdens of treatment would outweigh the expected benefits, OR
(b) Choice to Prolong Life
I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.
(2.2)
RELIEF FROM PAIN: Except as I state in the following space, I direct that treatment for alleviation of pain or
discomfort be provided at all times, even if it hastens my death:
(Add additional sheets if needed.)
(2.3)
OTHER WISHES: (If you do not agree with any of the optional choices above and wish to write your own, or if you
wish to add to the instructions you have given above, you may do so here.) I direct that:
(Add additional sheets if needed.)
PART 3
DONATION OF ORGANS AT DEATH
(OPTIONAL)
(3.1)
Upon my death (mark applicable box):
(a) I give any needed organs, tissues, or parts, OR
(b) I give the following organs, tissues, or parts only.
(c) My gift is for the following purposes (strike any of the following you do not want):
(1) Transplant
(2) Therapy
(3) Research
(4) Education
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