Medical Directive Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.ALL THE INFORMATION YOU PROVIDE IN THIS QUESTIONNAIRE IS STRICTLY CONFIDENTIAL Pennsylvania law gives you the right to direct and control the health care treatment you receive. While you are physically and mentally well enough to personally direct your own care, you will be in complete charge of the treatments provided to you. Once you become unable to understand the medical information provided to you, reach a decision, or communicate the decision to others, an Advanced Healthcare Directive will allow you to continue to have control over your care and treatment. Please keep in mind that no document, no matter how well drafted, is a substitute for thoughtful, informed medical decision making grounded upon conversations between you and your doctor, your doctor, and your healthcare agent, and MOST IMPORTANTLY, between you and your healthcare agent, BEFORE the loss of capacity. Should you have any questions or need clarification do not hesitate to contact our office to discuss your questions, comments, or concerns. PART I – HEALTH CARE POWER OF ATTORNEY AGENTS The agent under a health care power of attorney has the power to make decisions on your behalf on a variety of health-related issues when you are incapacitated. A good agent is honest and loyal, understands your goals and beliefs regarding end-of-life care, does not live far away, and is mentally and physically capable of acting on your behalf when you are unwilling or unable. A secondary agent should be named as a back-up in case the primary agent is unwilling or unable to serve. Designate your primary agent, and at least one alternative agent, Include contact information for each. PRIMARY AGENT: Name *FirstLastRelation to You: *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome Phone *Cell Phone *Email *FIRST ALTERNATE AGENT: Name *FirstLastRelation to You: *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome Phone *Cell Phone *Email *SECOND ALTERNATE AGENT: Name *FirstLastRelation to You: *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome Phone *Cell Phone *Email *THIRD ALTERNATE AGENT: Name *FirstLastRelation to You: *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome Phone *Cell Phone *Email *PART II – HEALTH CARE TREATMENT INSTRUCTIONS SITUATION ONE If I am in a coma or in a present vegetative state, and if after a period of at least: (# of months)And this many physicians agree that I will never again be able to think or recognize anyone or do even the simple things like eating, walking, or caring for my own hygiene: (# of physicians)Then I direct the following: 1. Cardiopulmonary Resuscitation (CPR) *PerformDo NOT performLet my Agent decide2. Mechanical Breathing: If, after diagnosis, I require medical assistance with breathing: *Connect me to a respiratorDo NOT connect me to a respiratorConnect me for a trial period. Remove me if my condition does not improveLet my Agent decide3. Tube Feeding *I want to be tube-fedI do NOT want to be tube-fedTube feed me for a trial period. End if my condition does not improve.Let my Agent decide4. Kidney Dialysis *Put me on dialysisDo NOT put me on dialysisPut me on dialysis for a trial period. End dialysis if my condition does not improveLet my Agent decide5. Diagnostic Tests *Perform necessary diagnostic testDo NOT perform diagnostic testOnly perform if they are necessary to determine the cause of my painLet my Agent decide6. Minor Surgery *Perform necessary minor surgeryDo NOT perform minor surgeryOnly perform if it is necessary to determine the cause of my painLet my Agent decide7. Major Surgery *Perform necessary minor surgeryDo NOT perform minor surgeryOnly perform if it is necessary to determine the cause of my painLet My Agent Decide8. Chemotherapy *I want chemotherapyI do NOT want chemotherapyPerform chemotherapy for a trial period. End if my condition does not improveLet my Agent decide9. Blood Transfusion *I want to receive blood transfusionsI do NOT want to receive blood transfusionsI want blood transfusions for a trial period. End if my condition does not improveLet my Agent decide10. Antibiotics *I want to receive antibioticsI do NOT want to receive antibioticsI want to receive antibiotics for a trial period. End if my condition does not improveLet my Agent Decide11. Pain Medication and Comfort Care *If I am in pain, I want to receive enough medication to stop the painI do NOT want to receive pain medicationLet my Agent decideI want to be kept clean, turned frequently, and receive whatever other care is necessary to maintain my dignityADDITIONAL COMMENTS: If you want to add any further instructions or clarifications regarding Situation One, please use the space provided here. SITUATION TWO If I have sustained a head injury and/or am in a coma with physicians in agreement that the extent of the damage is unknown and the long-range outcome is unpredictable, then I direct the following: 1. Cardiopulmonary Resuscitation (CPR) *PerformDo NOT performLet my Agent decide2. Mechanical Breathing: If, after diagnosis, I require medical assistance with breathing: *Connect me to a respiratorDo NOT connect me to a respiratorConnect me for a trial period. Remove me if my condition does not improveLet my Agent decide3. Tube Feeding *I want to be tube-fedI do NOT want to be tube-fedTube feed me for a trial period. End if my condition does not improve.Let my Agent decide4. Kidney Dialysis *Put me on dialysisDo NOT put me on dialysisPut me on dialysis for a trial period. End dialysis if my condition does not improveLet my Agent decide5. Diagnostic Tests *Perform necessary diagnostic testDo NOT perform diagnostic testOnly perform if they are necessary to determine the cause of my painLet my Agent decide6. Minor Surgery *Perform necessary minor surgeryDo NOT perform minor surgeryOnly perform if it is necessary to determine the cause of my painLet my Agent decide7. Major Surgery *Perform necessary minor surgeryDo NOT perform minor surgeryOnly perform if it is necessary to determine the cause of my painLet My Agent Decide8. Chemotherapy *I want chemotherapyI do NOT want chemotherapyPerform chemotherapy for a trial period. End if my condition does not improveLet my Agent decide9. Blood Transfusion *I want to receive blood transfusionsI do NOT want to receive blood transfusionsI want blood transfusions for a trial period. End if my condition does not improveLet my Agent decide10. Antibiotics *I want to receive antibioticsI do NOT want to receive antibioticsI want to receive antibiotics for a trial period. End if my condition does not improveLet my Agent Decide11. Pain Medication and Comfort Care *If I am in pain, I want to receive enough medication to stop the painI do NOT want to receive pain medicationLet my Agent decideI want to be kept clean, turned frequently, and receive whatever other care is necessary to maintain my dignityADDITIONAL COMMENTS: If you want to add any further instructions or clarifications regarding Situation One, please use the space provided here. SITUATION THREE If I am suffering from degenerative brain disease, such as Alzheimer’s, and I have deteriorated to the point where I am no longer able to understand things or make decisions, AND I ALSO DEVELOP A TERMINAL ILLNESS, then I direct the following: 1. Cardiopulmonary Resuscitation (CPR) *PerformDo NOT performLet my Agent decide2. Mechanical Breathing: If, after diagnosis, I require medical assistance with breathing: *Connect me to a respiratorDo NOT connect me to a respiratorConnect me for a trial period. Remove me if my condition does not improveLet my Agent decide3. Tube Feeding *I want to be tube-fedI do NOT want to be tube-fedTube feed me for a trial period. End if my condition does not improve.Let my Agent decide4. Kidney Dialysis *Put me on dialysisDo NOT put me on dialysisPut me on dialysis for a trial period. End dialysis if my condition does not improveLet my Agent decide5. Diagnostic Tests *Perform necessary diagnostic testDo NOT perform diagnostic testOnly perform if they are necessary to determine the cause of my painLet my Agent decide6. Minor Surgery *Perform necessary minor surgeryDo NOT perform minor surgeryOnly perform if it is necessary to determine the cause of my painLet my Agent decide7. Major Surgery *Perform necessary minor surgeryDo NOT perform minor surgeryOnly perform if it is necessary to determine the cause of my painLet My Agent Decide8. Chemotherapy *I want chemotherapyI do NOT want chemotherapyPerform chemotherapy for a trial period. End if my condition does not improveLet my Agent decide9. Blood Transfusion *I want to receive blood transfusionsI do NOT want to receive blood transfusionsI want blood transfusions for a trial period. End if my condition does not improveLet my Agent decide10. Antibiotics *I want to receive antibioticsI do NOT want to receive antibioticsI want to receive antibiotics for a trial period. End if my condition does not improveLet my Agent Decide11. Pain Medication and Comfort Care *If I am in pain, I want to receive enough medication to stop the painI do NOT want to receive pain medicationLet my Agent decideI want to be kept clean, turned frequently, and receive whatever other care is necessary to maintain my dignityADDITIONAL COMMENTS: If you want to add any further instructions or clarifications regarding Situation One, please use the space provided here. SITUATION FOUR If I am suffering from a degenerative brain disease, such as Alzheimer’s, and I have deteriorated to the point where I am no longer able to understand things or make decisions, BUT I DO NOT HAVE A TERMINAL ILLNESS, then I direct the following: 1. Cardiopulmonary Resuscitation (CPR) *PerformDo NOT performLet my Agent decide2. Mechanical Breathing: If, after diagnosis, I require medical assistance with breathing: *Connect me to a respiratorDo NOT connect me to a respiratorConnect me for a trial period. Remove me if my condition does not improveLet my Agent decide3. Tube Feeding *I want to be tube-fedI do NOT want to be tube-fedTube feed me for a trial period. End if my condition does not improve.Let my Agent decide4. Kidney Dialysis *Put me on dialysisDo NOT put me on dialysisPut me on dialysis for a trial period. End dialysis if my condition does not improveLet my Agent decide5. Diagnostic Tests *Perform necessary diagnostic testDo NOT perform diagnostic testOnly perform if they are necessary to determine the cause of my painLet my Agent decide6. Minor Surgery *Perform necessary minor surgeryDo NOT perform minor surgeryOnly perform if it is necessary to determine the cause of my painLet my Agent decide7. Major Surgery *Perform necessary minor surgeryDo NOT perform minor surgeryOnly perform if it is necessary to determine the cause of my painLet My Agent Decide8. Chemotherapy *I want chemotherapyI do NOT want chemotherapyPerform chemotherapy for a trial period. End if my condition does not improveLet my Agent decide9. Blood Transfusion *I want to receive blood transfusionsI do NOT want to receive blood transfusionsI want blood transfusions for a trial period. End if my condition does not improveLet my Agent decide10. Antibiotics *I want to receive antibioticsI do NOT want to receive antibioticsI want to receive antibiotics for a trial period. End if my condition does not improveLet my Agent Decide11. Pain Medication and Comfort Care *If I am in pain, I want to receive enough medication to stop the painI do NOT want to receive pain medicationLet my Agent decideI want to be kept clean, turned frequently, and receive whatever other care is necessary to maintain my dignityADDITIONAL COMMENTS: If you want to add any further instructions or clarifications regarding Situation One, please use the space provided here. AUTHORITY OF INSTRUCTIONS OVER AGENT You have the choice of either: (1) require your agent to be bound to the instructions contained withing your Advanced healthcare Directive; or (2) allow your agent to use the instructions as guidance and potentially override your instructions, subject to any specific limitations. Please indicate your preference: *My health care agent MUST FOLLOW these instructions.My health care agent may treat these instructions as guidance, and shall have the final say and may override my instructions, subject to the following limitations:Any additional information:After you have carefully considered what medical treatments, you would want to accept or reject if you were in any of the situations described above, it is important that you and your selected health care agent discuss these options and the reasons behind your decision (personal, religious, ethical, moral, etc.) PART III - ANATOMICAL GIFTS Do you consent to donate your organs, tissues, and any other part or all of your body at the time of your death? *YesNoCheck all that apply:I consent to the donation for BOTH medical study and transplantsI consent to the donation ONLY for medical studyI consent to the donation ONLY for transplantsI consent to the donation subject to the following limitationsAny additional information:Submit Call Us 888-357-3197 Address 33 Robinhood DrEtters, PA, 17319-9321, US Send a Message Name Email Address Message Submit