Advance Directive for Health
Care
I,
______________________________________, write this document as a
directive regarding my medical care.
In the following sections, put
the initials of your name in the blank
spaces by the choices you
want.
PART I. My Durable Power
of Attorney for Health Care
______ I appoint this person to make
decisions about my medical care if there ever comes a time when I
cannot make those decisions myself. I want the person I appointed,
my doctors, my family and others to be guided by decisions I have
made in the parts of the form
that follow.
Name:________________________________________________
Home
Telephone:_____________________________________________
Work
Telephone:
____________________________________________
Address:
______________________________________________
______________________________________________
If the person above
cannot or will not make decisions for me, I appoint this
person.
Name:________________________________________________
Home
Telephone:_____________________________________________
Work
Telephone:
____________________________________________
Address:
______________________________________________
______________________________________________
_______ I have not
appointed anyone to make health care decisions for me in this or any
other document.
PART 2. My Living
Will
These are my wishes for
my future medical care if there ever comes a time when I can’t make
these decisions for myself.
A. These are my wishes if I
have a terminal condition.
Life-sustaining
treatments
_______ I do not want
life-sustaining treatments (including CPR) started. If
life-sustaining treatments are started, I want them
stopped.
_______ I want
life-sustaining treatments that my doctors think are best for
me.
_______ Other wishes.
_______________________________
___________________________________________
Artificial nutrition and
hydration
_______ I do not want
artificial nutrition and hydration started if they would be the main
treatments keeping me alive. If artificial nutrition and hydration
are started, I want them stopped.
_______ I want
artificial nutrition and hydration even if they are the main
treatments keeping me alive.
_______ Other wishes.
_______________________________
___________________________________________
Comfort
care
_______ I want to be
kept as comfortable and free of pain as possible, even if such care
prolongs my dying or shortens my life.
_______ Other wishes.
_______________________________
___________________________________________
B. These are my wishes if I am
ever present in a persistent vegetative
state.
Life-sustaining treatments
These are my wishes for my future medical care if
there ever comes a time when I can’t make these decisions for
myself.
A. These are my wishes if I have a terminal
condition.
Life-sustaining
treatments
_______ I do not want life-sustaining treatments
(including CPR) started. If life-sustaining treatments are started,
I want them stopped.
_______ I want life-sustaining treatments that my
doctors think are best for me.
_______ Other wishes.
_______________________________
___________________________________________
Artificial nutrition and
hydration
_______ I do not want artificial nutrition and
hydration started if they would be the main treatments keeping me
alive. If artificial nutrition and hydration are started, I want
them stopped.
_______ I want artificial nutrition and hydration even
if they are the main treatments keeping me alive.
_______ Other wishes.
_______________________________
___________________________________________
Comfort care
_______ I want to be kept as comfortable and free of
pain as possible, even if such care prolongs my dying or shortens my
life.
_______ Other wishes.
_____________________________
C. Other
Directions
You have the right to be involved in all decisions
about your medical care, even those not dealing with terminal
conditions or persistent vegetative states. If you have wishes not
covered in other parts of this document, please indicate them
below.
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
PART 3.
Other Wishes
_______ I do not wish to donate any of my organs or
tissues.
_______ I want to donate all of my organs and
tissues.
_______ I only want to donate these organs and
tissues:
_________________________________________
_______ Other
wishes.______________________________
_________________________________________
B.
Autopsy
_______ I do not want an autopsy.
_______ I agree to an autopsy if my doctor recommends
it.
_______ Other
wishes.______________________________
_________________________________________
C. Other
statements about your medical care
If you wish to say more about any of the choices you
have made or if you have any other statements to make about your
medical care, you may do so on a separate sheet of paper. If you do
so, put here the number of pages you are adding: ________
PART 4.
Signatures
You and two witnesses must sign this document before
it will be legal.
A. Your signature
By my signature below, I show that I understand the
purpose and the effect of this document.
Signature: _________________________ Date:
_____________
Name Printed: ___________________________
Address:
_____________________________________________
_____________________________________________________
B. Your
witnesses’ signatures
I
believe the person who has signed this advanced directive to be of
sound mind, that he/she signed or acknowledged this advance
directive in my presence and that he/she appears not to be acting
under pressure, duress, fraud or undue influence. I am not related
the person making this advance directive by blood, marriage or
adoption nor, to the best of my knowledge, am I named in his/her
will. I am not the person appointed in this advance directive. I am
not a health care provider or an employee of a health care provider
who is now, or has been in the past, responsible for the care of the
person making this advance directive.
Witness # 1
Signature: _________________________ Date:
_____________
Name Printed: ___________________________
Address:
_____________________________________________
_____________________________________________________
Witness # 2
Signature: _________________________ Date:
_____________
Name Printed: ___________________________
Address:
_____________________________________________
_____________________________________________________
Adapted with permission
from the District of Colombia Hospital Association, 1250 Eye, N.W.,
Suite 700, Washington, DC
