This form should be recognised in most parts of the USA.
PART 1. 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 have appointed, my doctors, my family and others to be guided by the 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 treatment (including CPR) started. If life-sustaining treatments are started, I want them stopped.
______ I want the 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 in a persistent vegetative state.
Life-sustaining treatments
______ I do not want life-sustaining treatment (including CPR) started. If life-sustaining treatments are started, I want them stopped.
______ I want the 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
A. Organ donation
______ 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 doctors wish 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 piece 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:
Address:
B. Your witnesses' signatures
I believe the person who has signed this advance 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 to 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:
Address:
Witness #2
Signature: Date:
Address: