Logan County Advance Directive Form

ADVERTISEMENT

ADVANCED DIRECTIVES OF ________________________________
This document contains the following:
1. my Living Will or Health Care Instructions,
2. my Appointment of a Health Care Agent,
3. my Appointment of an Attorney-in-Fact for Health Care Decisions, and
4. the Designation of the Conservator of my Person regarding my Future Incapacity.
As my physician, you may rely upon any information given to you by my health care agent and
decisions made by my attorney-in-fact and my conservator if I am unable to make a given decision for
myself.
LIVING WILL OR HEALTH CARE INSTRUCTIONS
If the time comes when I am incapacitated to the extent that I can no longer take part in decisions for
my own life, and I am unable to direct my physician as to my own medical care, I wish this statement
to stand as a testament of my wishes.
I, _____________________________, the author of these advanced directives, request that, if my
condition is judged to be terminal or if I am deemed to be permanently unconscious, I be allowed to
die and that I not be kept alive through life support systems. By “terminal condition,” I mean that I
have an irreversible or an incurable medical condition which, without the administration of life support
systems, will, in the judgment of my attending physician, result in death within a relatively short time.
By “permanently unconscious, ” I mean that I am in a permanent coma or persistent vegetative state
which is an irreversible condition in which I am at no time cognizant of myself or my environment and
demonstrate no behavioral response to my environment.
Specific Instructions
My instructions regarding particular types of life support systems are listed below. This list is not all-
inclusive. My general statement that I not be kept alive through life support systems is limited only
where I have indicated that I desire a particular treatment to be provided.
Provide
Withhold
Cardiopulmonary Resuscitation
_________
________
Artificial Respiration (including a respirator)
_________
________
Artificial means of providing nutrition and hydration
_________
________
_______________________________________________
_________
________
_______________________________________________
_________
________
Other specific requests:_____________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________
I want sufficient pain medication to maintain my physical comfort. I do not intend any direct taking of
my life, but intend only that my dying not be unreasonably prolonged.
*
Please read and complete the Advanced Directives (pages 1-4).

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go
Page of 4