Advance
Health Care Directive for
I,
_________________________________________________, complete this document as a
directive
(Print
your full name)
regarding my medical care.
(In the following sections, initial the blanks by the choices
you select)
PART 1. My Durable Power of Attorney for Health Care
Option
1: I, ______________________________, wish to
appoint a health care agent.
(Print
your full name)
I,
_____________________________________, appoint the following person to make
decisions for me
(Print
your full name)
concerning my medical care in the event
that I become unable to make these decisions for myself. I give my agent full
power and authority to make health care decisions for me including the right to
consent, refuse consent, or withdraw consent to any care, treatment, service,
or procedure to maintain, diagnose, or treat a physical or mental condition,
and to receive and to consent to the release of medical information, subject to
the statement of my desires, and special instructions. I want the individual I
have appointed, my family, doctors, and others to guide decisions on my medical
care based on my wishes expressed in the sections below.
Your agent may not be:
1. 1.
Your primary health
care provider.
2. 2.
An operator of a
residential care facility where you receive care.
3. 3.
An employee of the
health care institution or residential care facility where you receive care,
unless your agent is related to you or is one of your co-workers.
I hereby appoint:
The Reverend ,
S.J., the Religious Superior of the Jesuit Community at and his successors in that position.
AND/OR
Name Email:
(agent’s name)
Address:
(street address, city, state, zip code)
Home Phone: Work
Phone:
Cell Phone/Pager: Fax:
Option
2: I, _________________________________________,
do not wish to appoint anyone to make
(print your full name)
medical decisions for me at this time.
Option
3: I, _________________________________________,
want my agent’s authority to make
(print your full name)
health care decisions for me to start
now, even though I am still able to make them for myself.
PART 2.
My Instructions for Health Care
The following are
my wishes regarding my future medical care, in the event that I become unable
to make these decisions for myself. (Initial all choices that apply to you
or write in any additional wishes. If you do not initial any of the statements
below or write your own statement, your agent will have broad powers to make
health care decisions on your behalf, except to the extent that you have set
forth limitations, or as limited by state or federal law.)
These are my wishes if I have a
terminal condition or am in a persistent vegetative state. (If any statement reflects your
desires, you may initial it to make it part of your instructions)
Life-Sustaining
Treatments
1) I do not want my life to be prolonged
and I do not want life-sustaining treatment to be provided or continued: (1) if
I am in an irreversible coma or persistent vegetative state; or (2) if I am
terminally ill and the application of life-sustaining procedures would serve
only to artificially delay the moment of my death; or (3) under any other
circumstance where the burdens of the treatment outweigh the expected benefits.
I want my agent to consider the relief of suffering and the quality as well as
the extent of possible extension of my life in making decisions regarding
life-sustaining treatment.
If
this statement reflects your desires initial here:
OR:
2)
2)
I want my life to
be prolonged and I want life-sustaining treatment to be provided unless I am
in a coma or persistent vegetative state which my doctor reasonably feels
to be irreversible. Once my doctor has reasonably concluded that I will remain
unconscious for the rest of my life, I do not want life-sustaining
treatment to be provided or continued.
If
this statement reflects your desires initial here:
OR:
3)
3)
I
want my life to be prolonged to the greatest extent possible without regard to
my condition, the chance I have for recovery, or the cost of the procedures.
If this statement reflects your desires initial here:
Specific Life Sustaining Treatments
If I am
persistently unconscious or there is no reasonable expectation of my recovery
from a seriously incapacitating or terminal illness or condition, I direct that
all of the life prolonging procedures I have initialed below be withheld or
withdrawn unless they are being used to control pain or to provide comfort.
___________ Artificial nutrition and hydration (tube feeding of food and
water)
___________ Surgery
or other invasive procedures
___________ Cardiopulmonary
resuscitation
___________ Antibiotics
(for treating infection)
___________ Dialysis
(machine which does the work for the kidneys if they fail)
___________ Respirator
(machine which does the work for the lungs if they fail)
___________ Chemotherapy
(to kill cancer cells)
___________ Radiation
Therapy (to kill cancer cells)
___________ Other statements of desires, special instructions or
limitations:
______________________________________________________
______________________________________________________
(You may attach additional pages
if needed. You must date and sign any attached pages.)
Comfort Care
___________ I want to be kept as comfortable
and free of pain as possible, even if this care shortens my life.
___________ Other wishes:
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Contribution of Anatomical Gift
___________ I wish to be an organ donor. See
my driver’s license or the attached page(s) of instructions for any specifics.
OR:
___________ I do not wish to be an
organ donor.
Autopsy
___________ I
agree to an autopsy if my doctors wish it.
___________ I
do not want an autopsy.
___________ Other wishes regarding disposition of my body.
______________________________________________________
______________________________________________________
______________________________________________________
Additional
Directions
You
have the right to be involved in all directions regarding your medical care,
even if they do not relate to a terminal condition or a persistent vegetative
state. If you have additional wishes that have not already been covered, please
indicate them below or attach additional pages.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
___________ I have added additional pages of
specific health care instructions to this directive, each of which I have
signed and dated.
Signatures
You and
two witnesses must sign this document before it will be legal. The following persons cannot act as witness:
1. 1.
the persons you
have appointed as your health care agent
2. 2.
your health care
provider
3. 3.
an employee of your
health care provider
4. 4.
an operator or
employee of a residential care facility for the elderly
In addition, at least one of the witnesses cannot be related
to you by blood, marriage, or adoption.
This person cannot be named in your will or be entitled to any portion
of your estate upon your death.
Alternatively,
you may use a notary public to acknowledge this form.
Your Signature:
(date) (name printed) (signature)
Residence
Address:
First
Witness:
(date) (name printed) (signature)
Residence
Address:
Second Witness:
(date) (name printed) (signature)
Residence
Address: