HEALTH CARE DIRECTIVE PT SS#______-_____-______

I, ___________________________, born ___________________, understand this document allows me to do BOTH of the following:

PART 1: Name another person (called the health care agent) to make health care decisions for me if I am unable to decide or speak for myself. My health care agent must make health care decisions for me based on the instruction I provide in this document (Part II), if any, the wishes I have made known to him or her, or must act in my best interest if I have not made my health care wishes known.

and

PART II: Give health care instructions to guide others making health care decisions for me. If I have named a health care agent, these instructions are to be used by the agent. These instructions may also be used by my health care providers, others assisting with my health care and my family, in the event I cannot make decisions for myself.

PART I: APPOINTMENT OF HEALTH CARE AGENT

This is who I want to make health care decisions for me if I am unable to decide or speak for myself:

(I know I can change my agent or alternate agent at any time, and I know I do not have to appoint an agent or alternate agent.)

(NOTE: If you appoint an agent, you should discuss this health care directive with your agent and give your agent a copy. If you do not wish to appoint an agent, you may leave Part I bland and go to Part II.)

When I am unable to decide or speak for myself, I trust and appoint _________________ to make health care decisions for me. This person is called my health care agent.

Relationship of my health care agent to me: SPOUSE

Home phone # of my health care agent: __________________________________

Work phone # of my health care agent: __________________________________

Address of my health care agent: __________________________________

__________________________________

This is what I want my health care agent to be able to do if I am unable to decide or speak for myself.

(I know I can change these choices.)

My health care agent is automatically given the powers listed below in (a) through (d). My health care agent must follow my health care instructions in this document or any other instructions I have given to my agent. If I have not given health care instructions, then my agent must act in my best interest.

Whenever I am unable to decide or speak for myself, my health care agent has the power to:

(a) Make any health care decision for me. This includes the power to give, refuse, or withdraw consent to any care, treatment, service or procedures. This includes deciding whether to stop or not start health care which is keeping me or might keep me alive, and deciding about intrusive mental heath treatment.

(b) Choose my health care providers.

(d) Review my medical records and has the same rights that I would have to give my medical records to other people.

If I DO NOT want my health care agent to have a power listed above in (a) through (d), OR if I want to LIMIT any power in (a) through (d), I MUST say that here:

______________________________________________________________________________

My health care agent is NOT automatically given the powers listed in (1) and (2). If I WANT my agent to have any of the powers in (1) and (2), I must INITIAL the line in front of the power, then my agent WILL HAVE that power.

__________ (1) To decide whether to donate organs, tissues, or eyes.

__________ (2) To decide what will happen with my body when I die (burial, cremation).

If I want to say anything more about my health care agent's powers or limits on the powers, I can say it here:

______________________________________________________________________________

PART II: HEALTH CARE INSTRUCTIONS

(NOTE: Complete this Part II if you wish to give health care instructions. If you appointed an agent in Part I, completing this Part II is optional but would be very helpful to your agent. However, if you chose not to appoint an agent in Part I, you MUST complete some or all of this Part II if you wish to make a valid health care directive.)

These are instructions for my health care agent when I am unable to decide or speak for myself. These instructions must be followed (so long as they address my needs).

These are my beliefs and values about my health care:

(I know I can change these choices or leave any of them blank).

I want you to know these things about me to help you make decisions about my health care:

My goals for my health care: I believe that my health care should be directed toward preserving my self determination, well-being and dignity. I do not believe in the futile prolongation of life when there is no hope for recovery, nor in the unwanted and unnecessary prolongation of pain and suffering.

My fears about my health care: _______________________________

My spiritual or religious beliefs and traditions: _______________

My beliefs about when life would no longer be worth living: _____

My thoughts about how my medical condition might affect my family:

This is what I want and do not want for my health care:

(I know I can change these choices or leave any of them blank).

Many medical treatments may be used to try to improve my medical condition or to prolong my life. Examples include artificial breathing by a machine connected to a tube in the lungs, artificial feeding or fluids through tubes, attempts to start a stopped heart, surgeries, dialysis, antibiotics and blood transfusions. Most medical treatments can be tried for a while and then stopped if they do not help.

I have these views about my health care in these situations.

(NOTE: You can discuss general feelings, specific treatments or leave any of them blank.)

If I had a reasonable chance of recovery, and were temporarily unable to decide or speak for myself, I would want: My agent to use every resource available to bring me back to health.

If I were dying and unable to decide or speak for myself, I would want: All appropriate health care that would help aggressive management pain and suffering in protecting my dignity and hygiene in my terminal state.

I were permanently unconscious and unable to decide or speak for myself, I would want: No medical treatment of any kind, including artificially administered sustenance if I am clearly unable to communicate with my wishes. In other words, I only want those measures which will maintain comfort, hygiene and dignity.

If I were completely dependent on others for my care and unable to decide or speak for myself, I would want: No medical treatment of any kind, including artificially administered sustenance if I am clearly unable to communicate with my wishes. In other words, I only want those measures which will maintain comfort, hygiene and dignity.

In all circumstances, my doctors will try to keep me comfortable and reduce my pain. This is how I feel about pain relief if it would affect my alertness or if it could shorten my life: If my condition is terminal or there is significant dementia, I desire aggressive pain and suffering management regardless of how it affects the length of my life. Regarding alertness, if I am not alert enough to express my own wishes, then it is not a serious concern of mine.

There are other things that I want or do not want for my health care, if possible:

Who I would like to be my doctor: _____________________________________

Where I would like to receive my health care: ________________________

Where I would like to die and other wishes I have about dying: ___________________________

My wishes about donating parts of my body when I die: _________________

My wishes about what happens to my body when I die: (cremation, burial):_________

Any other things: ______________________________________________________

PART III: MAKING THE DOCUMENT LEGAL

This document must be signed by me. It also must either be verified by a notary public (Option 1) OR witnessed by two witnesses (Option 2). It must be dated when it is verified or witnessed.

I am thinking clearly, I agree with everything that is written in this document and I have made this document willingly.

_______________________________ ________________________

My Signature

Date of Birth: ____________________________

Address: ____________________________

____________________________

If I cannot sign my name, I can ask someone to sign this document for me:

______________________________________________________________________________

Signature of the person who I asked to sign this document for me:

______________________________________________________________________________

Printed name of the person who I asked to sign this document for me:

_____________________________________________________________________________

OPTION I: NOTARY PUBLIC

In my presence on __________________ (date), ___________________________________ (name) acknowledged his/her signature on this document or acknowledged that he/she authorized the person signing this document to sign on his/her behalf. I am not named as a health care agent or alternate health care agent in this document.

______________________________

Signature of Notary

OPTION 2: TWO WITNESSES

Two witnesses must sign. Only one of the two witnesses can be a health care provider or an employee of a health care provider given direct care to me on the day I sign this document.

Witness One:

i. In my presence on ________________ (date), __________________________________ (name) acknowledged his/her signature on this document or acknowledged that he/she authorized the person signing this document to sign on his/her behalf.

ii. I am at least 18 years old.

iii. I am not named as a health care agent or an alternate health care agent in this document.

iv. If I am a health care provider or an employee of a health care provider giving direct care to the person listed above in (a), I must initial this box: [ ]

I certify that the information in (i) through (iv) is true and correct.

___________________________________ Dated: ________________

Signature of Witness One

Date: of Birth: _______________________

Address: _______________________

_______________________

Witness Two:

ii. I am at least 18 years old.

iii. I am not named as a health care agent or an alternate health care agent in this document.

iv. If I am a health care provider or an employee of a health care provider giving direct care to the person listed above in (a), I must initial this box: [ ]

I certify that the information in (i) through (iv) is true and correct.

___________________________________ Dated: ________________

Signature of Witness One

Date: of Birth: _______________________

Address: _______________________

_______________________

(REMINDER: Keep this document with your personal papers in a safe place, not is a safe deposit box. Give signed copies to your doctors, family, close friends, health care agent and alternate health care agent. Make sure your doctor is willing to follow your wishes. This document should be part of your medical record at your doctor's office and at the hospital, home care agency, hospice or nursing facility where you receive your care.)